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Drieghe B, Hendrickx I, De Buyzere M, De Backer T. Double kiss mini-crush technique to treat complex recurrent renal artery in-stent restenosis. Catheter Cardiovasc Interv 2024; 104:92-96. [PMID: 38686525 DOI: 10.1002/ccd.31066] [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: 11/24/2023] [Revised: 02/23/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024]
Abstract
The double-kiss mini-crush (DKMC) technique has been successfully deployed in the past for the treatment of complex coronary lesions even for left main lesions. Our case report consists of a proof-of-principle that the DKMC technique can be successfully translated as well to the field of complex renal artery lesions. Insightful thinking out-of-the "coronary" box in concert with skillful off-label application of coronary stenting procedures may open the gate for unprecedented opportunities for the treatment of difficult-to-tackle in-stent restenosis in the renal circulation.
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Affiliation(s)
- Benny Drieghe
- Heart Center, University Hospital Gent, Gent, Belgium
| | - Ief Hendrickx
- Heart Center, University Hospital Gent, Gent, Belgium
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2
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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. [PMID: 38837309 DOI: 10.1002/ccd.31117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [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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3
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Triantis G, Chalikias GK, Ioannides E, Dagre A, Tziakas DN. Renal Artery Revascularization a controversial treatment strategy for Renal Artery Stenosis. A case series and a brief review of current literature. Hellenic J Cardiol 2022; 65:42-48. [PMID: 35341971 DOI: 10.1016/j.hjc.2022.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/24/2022] [Accepted: 03/19/2022] [Indexed: 11/04/2022] Open
Abstract
Renal artery stenosis (RAS) may cause secondary hypertension, progressive decline in renal function, and cardiac destabilization syndromes including "flash" pulmonary edema, recurrent congestive heart failure, and cerebro-cardiovascular disease. Atherosclerotic lesions, fibromuscular dysplasia and vasculitides are the pathophysiologic basis of the disease. Common therapeutic pathways for RAS include medical therapy and revascularization with or without stenting. Randomized controlled trials evaluating renal revascularization, did not report any advantage of revascularization over medical therapy alone in terms of renal function improvement or prevention of cardiovascular events. However, mounting clinical experience suggests that the best strategy in RAS management is identifying which patients are most likely to benefit from renal artery stenting and also optimizing the safety and durability of the procedure. This review presents 3 cases of patients who undergone renal revascularization and discusses the available clinical evidence for identification of RAS patients who will potentially respond well to revascularization.
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Affiliation(s)
| | - Georgios K Chalikias
- Department of Cardiology, Medical School, Democritus University of Thrace, Alexandroupolis
| | | | - Anna Dagre
- Department of Cardiology, Thriassio General Hospital, Athens, Greece
| | - Dimitrios N Tziakas
- Department of Cardiology, Medical School, Democritus University of Thrace, Alexandroupolis.
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4
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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: 8] [Impact Index Per Article: 2.0] [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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5
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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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6
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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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7
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Zierler RE, Jordan WD, Lal BK, Mussa F, Leers S, Fulton J, Pevec W, Hill A, Murad MH. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. J Vasc Surg 2018; 68:256-284. [PMID: 29937033 DOI: 10.1016/j.jvs.2018.04.018] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 12/20/2022]
Abstract
Although follow-up after open surgical and endovascular procedures is generally regarded as an important part of the care provided by vascular surgeons, there are no detailed or comprehensive guidelines that specify the optimal approaches with regard to testing methods, indications for reintervention, and follow-up intervals. To provide guidance to the vascular surgeon, the Clinical Practice Council of the Society for Vascular Surgery appointed an expert panel and a methodologist to review the current clinical evidence and to develop recommendations for follow-up after vascular surgery procedures. For those procedures for which high-quality evidence was not available, recommendations were based on observational studies, committee consensus, and indirect evidence. Recognizing that there are numerous published reports on the role of duplex ultrasound for surveillance of infrainguinal vein bypass grafts, the Society commissioned a systematic review and meta-analysis on this topic. The panel classified the strength of each recommendation and the corresponding quality of evidence on the basis of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system: recommendations were graded either strong or weak, and the quality of evidence was graded high, moderate, or low. The resulting recommendations represent a wide variety of open surgical and endovascular procedures involving the extracranial carotid artery, thoracic and abdominal aorta, mesenteric and renal arteries, and lower extremity arterial revascularization. The panel also identified many areas in which there was a lack of high-quality evidence to support their recommendations. This suggests that there are opportunities for further clinical research on testing methods, threshold criteria, and the role of surveillance as well as on the modes of failure and indications for reintervention after vascular surgery procedures.
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Affiliation(s)
| | | | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, Md
| | - Firas Mussa
- Department of Surgery Palmetto Health/University of South Carolina School of Medicine, Columbia, SC
| | - Steven Leers
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Joseph Fulton
- Department of Surgery, Westchester Medical Center, Poughkeepsie, NY
| | - William Pevec
- Division of Vascular Surgery, University of California, Davis, Sacramento, Calif
| | - Andrew Hill
- Division of Vascular & Endovascular Surgery, The Ottawa Hospital & University of Ottawa, Ottawa, Ontario, Canada
| | - M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, Minn
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8
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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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9
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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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10
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Ren X, Qiao A, Song H, Song G, Jiao L. Influence of Bifurcation Angle on In-Stent Restenosis at the Vertebral Artery Origin: A Simulation Study of Hemodynamics. J Med Biol Eng 2016. [DOI: 10.1007/s40846-016-0155-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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11
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Sarafidis PA, Stavridis KC, Loutradis CN, Saratzis AN, Pateinakis P, Papagianni A, Efstratiadis G, Saratzis N. To intervene or not? A man with multidrug-resistant hypertension, endovascular abdominal aneurysm repair, bilateral renal artery stenosis and end-stage renal disease salvaged with renal artery stenting. Blood Press 2015; 25:123-8. [DOI: 10.3109/08037051.2015.1110926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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12
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Tang F, Hu C, Wang Q, Long W, Li L. A Novel Approach to Overcome Stent Strut Entrapment of the Distal Filter Retrieval Catheter during Vertebral Artery Stenting: The "Olive-Tipped" Technique. Ann Vasc Surg 2015; 30:309.e11-5. [PMID: 26522582 DOI: 10.1016/j.avsg.2015.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 07/01/2015] [Accepted: 07/17/2015] [Indexed: 11/20/2022]
Abstract
We developed an "olive-tipped" technique for preventing the distal filter retrieval catheter from entrapment in the stent struts during retrieval procedures after stent deployment and which we used in 2 vertebral artery stenting cases. A new wire entry port was made in the catheter at the transition of larger and smaller lumen to permit passage of a low-profile balloon into the lumen of the retrieval catheter. When the balloon was inflated across the retrieval catheter tip, a smoother profile was created which eliminated the sharp step between the catheter tip and the filter wire. The retrieval catheter could then be advanced easily through the stent struts using this modified system.
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Affiliation(s)
- Feng Tang
- Department of Vascular Surgery, First Hospital of Tsinghua University, Beijing, China
| | - Chang Hu
- Department of Vascular Surgery, First Hospital of Tsinghua University, Beijing, China
| | - Qian Wang
- Department of Vascular Surgery, First Hospital of Tsinghua University, Beijing, China
| | - Whitney Long
- Department of Vascular Surgery, First Hospital of Tsinghua University, Beijing, China
| | - Lei Li
- Department of Vascular Surgery, First Hospital of Tsinghua University, Beijing, China.
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13
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14
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Sammel AM, Wolfenden HD, Joshua F, Jepson N. Reduced efficacy of transcatheter and surgical revascularization in Takayasu arteritis. Int J Rheum Dis 2014; 22:152-157. [DOI: 10.1111/1756-185x.12549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Anthony M. Sammel
- Department of Rheumatology; Prince of Wales Hospital; Sydney NSW Australia
- Prince of Wales Clinical School; University of New South Wales; Sydney NSW Australia
| | - Hugh D. Wolfenden
- Department of Cardiothoracic Surgery; Prince of Wales Hospital; Sydney NSW Australia
| | - Fredrick Joshua
- Department of Rheumatology; Prince of Wales Hospital; Sydney NSW Australia
- Prince of Wales Clinical School; University of New South Wales; Sydney NSW Australia
| | - Nigel Jepson
- Prince of Wales Clinical School; University of New South Wales; Sydney NSW Australia
- Department of Cardiology; Prince of Wales Hospital; Sydney NSW Australia
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15
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Campbell JE, Stone PA, Bates MC. Technical discussion of diagnostic angiography and intervention of atherosclerotic renal artery stenosis. Semin Vasc Surg 2014; 26:150-60. [PMID: 25220320 DOI: 10.1053/j.semvascsurg.2014.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Renal artery stenting remains an important adjuvant treatment for true-resistant hypertension, although recent disappointing randomized trials highlight the importance of careful patient selection. Safe and successful renal interventions begin with critical core knowledge regarding renal artery anatomy and understanding the often hostile nature of the parent vessel (pararenal aorta). Armed with fundamental knowledge about anatomy and renal ostial disease pathology, it becomes easier to understand the advantages of less traumatic access techniques and how low-profile contemporary flexible stents have enhanced outcomes. In addition to suggested techniques based on detailed understanding of the vessel architecture and pathology, we will review the current available US Food and Drug Administration-approved balloon-expandable on-label renal stents and discuss the role of intravascular ultrasound for definition of lesion severity, stent sizing, and stent apposition. The durability of renal stenting will also be discussed, as will the velocity criteria for duplex surveillance. Lastly, the current empirical data related to renal embolic protection is provided, along with insight into technical issues in this domain.
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Affiliation(s)
- John E Campbell
- Department of Surgery, West Virginia University Division of Vascular and Endovascular Surgery, Vascular Center of Excellence, Charleston Area Medical Center, 3100 MacCorkle Avenue SE, Charleston, West Virginia 25304.
| | - Patrick A Stone
- Department of Surgery, West Virginia University Division of Vascular and Endovascular Surgery, Vascular Center of Excellence, Charleston Area Medical Center, 3100 MacCorkle Avenue SE, Charleston, West Virginia 25304
| | - Mark C Bates
- Department of Surgery, West Virginia University Division of Vascular and Endovascular Surgery, Vascular Center of Excellence, Charleston Area Medical Center, 3100 MacCorkle Avenue SE, Charleston, West Virginia 25304
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16
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Marshall RH, Schiffman MH, Winokur RS, Talenfeld AD, Siegel DN. Interventional Radiologic Techniques for Screening, Diagnosis and Treatment of Patients with Renal Artery Stenosis. Curr Urol Rep 2014; 15:414. [DOI: 10.1007/s11934-014-0414-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Peixoto AJ, Ditchel LM, Santos SFF. Management of atherosclerotic renal artery stenosis. Expert Rev Cardiovasc Ther 2014; 8:1317-24. [DOI: 10.1586/erc.10.85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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Tang F, Wang Q, Hu C, Li P, Li L. Use of the Szabo Technique to Guide Accurate Stent Placement at the Vertebral Artery Ostium. J Endovasc Ther 2013; 20:554-60. [DOI: 10.1583/13-4298.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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19
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Sarkodieh J, Walden S, Low D. Imaging and management of atherosclerotic renal artery stenosis. Clin Radiol 2013; 68:627-35. [DOI: 10.1016/j.crad.2012.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 11/14/2012] [Accepted: 11/20/2012] [Indexed: 11/30/2022]
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20
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Ndoye Diop A, Vo Hoang V, Cassagnes L, Alfidja Lankoaonde A, Dumousset E, Ravel A, Boyer L, Chabrot P. Treatment of atheromatous renal artery in-stent restenosis in 51 patients. Diagn Interv Imaging 2012; 94:68-77. [PMID: 23218478 DOI: 10.1016/j.diii.2012.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate our treatment of renal artery in-stent restenosis. PATIENTS AND METHODS Monocentric retrospective study of 53 cases of restenosis and two occlusions in 51 patients detected via systematic follow-up with imaging (72.5%) and/or deterioration of kidney function (5.9%) and/or blood pressure failure (54.9%), 15.7 months (5-121) after implantation, giving rise to 49 recalibrations via a balloon and five additional stentings. Analysis of the technical results, the effects on blood pressure and kidney function after repeated revascularizations. RESULTS Secondary permeability of 38 arteries (63.2%) after 12.4 months (3-64) with 14 second restenoses; 33.3% after redilation with a balloon, 60% after renewed stenting, more common in smokers (P=0.02), in case of peripheral arterial disease (P=0.02), ostial location (P=0.049) and kidney function impairment at the time of diagnosis of the restenosis (P=0.012). After 12.7 months (3-64) post-revascularization, kidney function was improved in 30% of patients and stabilised in 50% of patients. Treatment of second restenoses: one failure (7.1%), nine dilations with a balloon, three cutting balloon, one second stent. Treatment of third restenoses: 71.4% treated with a balloon (2), cutting balloon (2) or coated stent (DES) (1); then permeability at a later point in time: 50%. CONCLUSION The treatment of repeated restenoses with conventional techniques is of imperfect efficacy, and currently remains un-codified.
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Affiliation(s)
- A Ndoye Diop
- Service de Radiologie B [Radiology Department B], CHU de Clermont-Ferrand, University Hospital Centre, BP 69, 63003 Clermont-Ferrand, France
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21
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Boateng FK, Greco BA. Renal artery stenosis: prevalence of, risk factors for, and management of in-stent stenosis. Am J Kidney Dis 2012; 61:147-60. [PMID: 23122491 DOI: 10.1053/j.ajkd.2012.07.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 07/17/2012] [Indexed: 11/11/2022]
Abstract
Atherosclerotic renal artery stenosis is common and is associated with hypertension and chronic kidney disease. More frequent use of percutaneous renal artery stent placement for the treatment of renal artery stenosis during the past 2 decades has increased the number of patients with implanted stents. In-stent stenosis is a serious problem, occurring more frequently than earlier reports suggest and potentially resulting in late complications. Currently, there are no guidelines covering the approach to restenosis after renal artery stent placement. This article reviews data on the prevalence of and risk factors for the development of in-stent stenosis and the clinical manifestations, evaluation, and treatment of in-stent stenosis and suggests a strategy for the management of patients after percutaneous renal artery stent placement.
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Affiliation(s)
- Frank K Boateng
- Indiana University, Bloomington Hospital, Bloomington, IN, USA
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22
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Abstract
Renal artery intervention to treat hypertension is one of the frontiers of ongoing research in combating this epidemic. This article focuses on recent data regarding PTRS and catheter-based renal sympathetic denervation. Despite progress in this field large multicenter, randomized trials that compare these treatment modalities with medical therapy for hypertension are lacking.
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Affiliation(s)
- Rajan A G Patel
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA 70121, USA
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23
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Margey R, Hynes BG, Moran D, Kiernan TJ, Jaff MR. Atherosclerotic renal artery stenosis and renal artery stenting: an evolving therapeutic option. Expert Rev Cardiovasc Ther 2011; 9:1347-60. [PMID: 21985547 DOI: 10.1586/erc.11.143] [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: 11/08/2022]
Abstract
Atherosclerotic renal artery stenosis is a common clinical problem for which the optimal therapeutic strategy remains to be defined. However, renal artery stenting procedures have significantly increased as one approach to treat this clinical problem. Despite improvements in device design and technical performance of the procedure, the benefits and results of randomized clinical trials of renal artery stenting as a therapy remain confusing. Understanding the epidemiology, pathophysiology and natural history of renal artery stenosis are central to improving the outcomes of renal artery stenting. Developing both noninvasive and invasive predictive tools to better identify which patient will respond to renal revascularization will also be beneficial. In this article, we will present an overview of atherosclerotic renal artery disease. The results of renal artery stenting will be discussed and from this, the available noninvasive and invasive tools available to assess the clinical and hemodynamic significance of renal artery stenosis will be presented.
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Affiliation(s)
- Ronan Margey
- Section of Vascular Medicine, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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24
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PTA of a renal artery stenosis with a new embolization protection device: Evidence of side-branch occlusion due to distal embolization — A case report. Int J Angiol 2011. [DOI: 10.1007/s00547-001-0046-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Hatano T, Tsukahara T, Miyakoshi A, Arai D, Yamaguchi S, Murakami M. Stent placement for atherosclerotic stenosis of the vertebral artery ostium: angiographic and clinical outcomes in 117 consecutive patients. Neurosurgery 2011; 68:108-16; discussion 116. [PMID: 21099720 DOI: 10.1227/neu.0b013e3181fc62aa] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Although it is thought to be a safe treatment option, the main concerns related to treating vertebral artery ostium (VAO) stenosis with stents have been the rate of restenosis and the uncertain long-term results. OBJECTIVE To evaluate the angiographic and clinical results of stent placement for atherosclerotic stenosis of the VAO. METHODS One hundred seventeen consecutive patients with atherosclerotic VAO stenosis were treated with stent placement over a period of 12 years. All patients were retrospectively analyzed through the use of a prospectively collected database. The indication criteria for this treatment protocol were symptomatic severe VAO stenoses (> 60%) and asymptomatic severe VAO stenoses (> 60%) with incidentally detected infarction in the posterior circulation. The target diameter of stent dilatation from 1997 to 2000 was the normal vessel diameter just distal to the lesion. Moderate overdilation in the proximal portion of the stents has been performed since 2001. RESULTS Successful dilatation was obtained in 116 of 117 cases. Transient neurological complications developed in 2 patients; however, no patients experienced any permanent neurological complications. One hundred four patients underwent follow-up angiography at 6 months after stenting. The restenosis rate at the 6-month follow-up was 9.6% (10 of 104). Until 2000, the restenosis rate after stenting was 13.3%. Since 2001, the restenosis rate has decreased to 4.5%. The median clinical follow-up period was 48 months. The annual rate of strokes in the posterior circulation was 0.95%. CONCLUSION Stent placement for atherosclerotic VAO stenosis is considered to be a feasible and safe treatment and may be effective for stroke prevention. The moderate overdilation of stents may be an effective modality for the prevention of restenosis.
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Affiliation(s)
- Taketo Hatano
- Department of Neurosurgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan.
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Messerli FH, Bangalore S, Makani H, Rimoldi SF, Allemann Y, White CJ, Textor S, Sleight P. Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering Syndrome. Eur Heart J 2011; 32:2231-5. [PMID: 21406441 DOI: 10.1093/eurheartj/ehr056] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Franz H Messerli
- Division of Cardiovascular Medicine, St Luke's and Roosevelt Hospitals, Columbia University College of Physicians and Surgeons, 1000 Tenth Avenue, New York, NY 10019, USA.
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Henry M, Henry I, Polydorou A, Hugel M. Renal angioplasty stenting under embolic protection device: first human study with the FiberNet™ 3D filter. Interv Cardiol 2010. [DOI: 10.2217/ica.10.62] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Safety and Efficacy of Renal Artery Stenting Following Suboptimal Renal Angioplasty for De Novo and Restenotic Ostial Lesions: Results from a Nonrandomized, Prospective Multicenter Registry. J Vasc Interv Radiol 2010; 21:627-37. [DOI: 10.1016/j.jvir.2010.01.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Revised: 01/15/2010] [Accepted: 01/23/2010] [Indexed: 11/19/2022] Open
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An Analysis Comparing Open Surgical and Endovascular Treatment of Atherosclerotic Renal Artery Stenosis. Eur J Vasc Endovasc Surg 2009; 38:666-75. [DOI: 10.1016/j.ejvs.2009.08.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 08/10/2009] [Indexed: 11/21/2022]
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Contemporary management of atherosclerotic renovascular disease. J Vasc Surg 2009; 50:1197-210. [DOI: 10.1016/j.jvs.2009.05.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 05/15/2009] [Accepted: 05/17/2009] [Indexed: 01/13/2023]
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Topaz O, Polkampally PR, Topaz A, Polkampally CR, Jara J, Rizk M, McDowell K, Feldman G. Utilization of excimer laser debulking for critical lesions unsuitable for standard renal angioplasty. Lasers Surg Med 2009; 41:622-7. [PMID: 19816915 DOI: 10.1002/lsm.20854] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The energy emitted by ultraviolet laser is avidly absorbed in atherosclerotic plaques. Conceptually, it could be applied for debulking of selected atherosclerotic renal artery stenoses. We describe early experience with revascularization of critical renal artery lesions deemed unsuitable for standard renal angioplasty. Institutional Review Board permission to conduct the data analysis was obtained. METHODS Among 130 percutaneous renal artery interventions with balloon angioplasty and adjunct stenting, there were 12 (9%) patients who underwent laser debulking prior to stenting. These patients presented with critical (95+/-3.5% stenoses) lesions (11 de novo, 1 stent restenosis) deemed unsuitable for standard renal angioplasty because of marked eccentricity and presence of thrombus. Indications for intervention included preservation of kidney function, treatment of uncontrolled hypertension, management of congestive heart failure, and treatment of unstable angina. Blood pressure and estimated glomerular filtration rate (eGFR) were measured pre- and 3 weeks post-intervention. RESULTS A baseline angiographic stenosis of 95+/-3.5% was reduced to 50+/-13% with laser debulking. There were no laser-induced complications. Post-stenting the angiographic residual stenosis was 0%. The mean gradient across the lesions was reduced from baseline 85+/-40 to 0 mmHg. A normal post-intervention antegrade renal flow was observed in all patients. Baseline mean systolic BP of 178+/-20 mmHg decreased to 132+/-12 mmHg (P<0.0001) and mean diastolic pressure of 85+/-16 mmHg reduced to 71+/-9 mmHg (P = 0.01). A pre-intervention mean eGFR of 47.7+/-19 ml/min/1.73 m(2) increased to 56+/-20.4 ml/min/1.73 m(2) (P = 0.05) post-procedure. The interventions were not associated with major renal or cardiac adverse events. During follow-up one patient developed transient contrast-induced nephropathy. CONCLUSIONS Debulking of select renal artery stenoses with laser angioplasty followed by adjunct stenting is feasible. Further prospective, randomized studies will be required to explore the role of debulking and laser angioplasty in renal artery revascularization.
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Affiliation(s)
- On Topaz
- Division of Cardiology and Nephrology, McGuire Veterans Affairs Medical Center, MCV/Virginia Commonwealth University School of Medicine, Richmond, Virginia 23249, USA.
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Diagnosis and management of atherosclerotic renal artery stenosis: improving patient selection and outcomes. Nat Rev Cardiol 2009; 6:176-90. [PMID: 19234498 DOI: 10.1038/ncpcardio1448] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 12/04/2008] [Indexed: 01/02/2023]
Abstract
Renal artery stenosis (RAS) is common among patients with atherosclerosis, and is found in 20-30% of individuals who undergo diagnostic cardiac catheterization. Renal artery duplex ultrasonography is the diagnostic procedure of choice for screening outpatients for RAS. Percutaneous renal artery stent placement is the preferred method of revascularization for hemodynamically significant RAS, and is favored over balloon angioplasty alone. Stent placement carries a class I recommendation for atherosclerotic RAS according to ACC and AHA guidelines. Discordance exists between the very high (>95%) procedural success rate and the moderate (60-70%) clinical response rate after renal stent placement, which is likely to be a result of poor selection of patients, inadequate angiographic assessment of lesion severity, and the presence of renal parencyhmal disease. Physiologic lesion assessment using translesional pressure gradients, and measurements of biomarkers (e.g. brain natriuretic peptide), or both, could enhance the selection of patients and improve clinical response rates. Long-term patency rates for renal stenting are excellent, with 5-year secondary patency rates greater than 90%. This Review will outline the clinical problem of atherosclerotic RAS and its diagnosis, and will critically assess treatment options and strategies to improve patients' outcomes.
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Steinwender C, Schützenberger W, Fellner F, Hönig S, Schmitt B, Focke C, Hofmann R, Leisch F. 64-Detector CT Angiography in Renal Artery Stent Evaluation: Prospective Comparison with Selective Catheter Angiography. Radiology 2009; 252:299-305. [DOI: 10.1148/radiol.2521081362] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Singer GM, Setaro JF, Curtis JP, Remetz MS. Distal Embolic Protection During Renal Artery Stenting: Impact on Hypertensive Patients With Renal Dysfunction. J Clin Hypertens (Greenwich) 2008; 10:830-6. [DOI: 10.1111/j.1751-7176.2008.00030.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kiernan TJ, Yan BP, Jaff MR. Renal artery revascularization: collaborative approaches for specialists. Adv Chronic Kidney Dis 2008; 15:363-9. [PMID: 18805382 DOI: 10.1053/j.ackd.2008.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endovascular revascularization for atherosclerotic renal artery stenosis (RAS) is the revascularization strategy of choice for patients with hemodynamically and clinically significant renal artery stenosis. Surgical revascularization is reserved for failed endovascular therapy or concomitant abdominal aortic surgery. Endovascular renal artery stenting is associated with excellent technical success, low complication rates, and acceptable long-term patency. This technique has been proven to be beneficial for preserving kidney function and stabilizing or improving blood pressure control in selected patients. Nevertheless, deterioration in kidney function after the procedure in 10% to 20% of cases may limit the immediate benefits of this technique. Atheroembolism appears to play an important role in the cause of kidney dysfunction after renal revascularization. Renal revascularization with a distal embolic protection device is a promising strategy in reducing the risk of atheroembolism and deterioration in kidney function.
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Corriere MA, Pearce JD, Edwards MS, Stafford JM, Hansen KJ. Endovascular management of atherosclerotic renovascular disease: early results following primary intervention. J Vasc Surg 2008; 48:580-7; discussion 587-8. [PMID: 18727962 DOI: 10.1016/j.jvs.2008.04.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 04/15/2008] [Accepted: 04/16/2008] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This retrospective review examines periprocedural morbidity and early functional responses to primary renal artery angioplasty and stenting (RA-PTAS) for patients with atherosclerotic renovascular disease (RVD). METHODS Consecutive patients undergoing primary RA-PTAS for hemodynamically significant atherosclerotic RVD with hypertension and/or ischemic nephropathy were identified from a prospectively maintained registry. Hypertension responses were determined based on pre- and post-intervention blood pressure measurements and medication requirements. Estimated glomerular filtration rate (eGFR) was used to determine renal function responses. Both hypertension and renal function responses were assessed at least three weeks after RA-PTAS. Stepwise multivariable regression analysis was used to examine associations between blood pressure and renal function responses to RA-PTAS and select clinical variables. RESULTS One-hundred ten primary RA-PTAS were performed on 99 patients with atherosclerotic RVD with a mean angiographic diameter-reducing stenosis of 79.2 +/- 12.9%. All patients had hypertension (mean of 3.4 +/- 1.3 antihypertensive agents). Mean pre-intervention eGFR was 49.9 +/- 22.7 mL/min/1.73 m(2), and 74 patients had a pre-intervention eGFR < 60 mL/min/1.73 m(2). The technical success rate for RA-PTAS was 94.5%. The periprocedural complication rate was 5.5%; there were no periprocedural deaths. Statistically significant decreases in mean systolic blood pressure (161.3 +/- 25.2 vs. 148.5 +/- 25.2 post-intervention, P < .0001), diastolic blood pressure (78.6 +/- 13.3 versus 72.5 +/- 13.5 post-intervention, P < .0001), and number of antihypertensive agents (3.3 +/- 1.2 versus 3.1+/- 1.3 post-intervention, P = .009) were observed. Assessed categorically, hypertension response to RA-PTAS was cured in 1.1%, improved in 20.5%, and unchanged in 78.4%. Categorical eGFR response to RA-PTAS was improved in 27.7%, unchanged in 65.1%, and worsened in 7.2%. Multivariable stepwise regression revealed associations between pre- and post-intervention systolic blood pressure (P < .0001), diastolic blood pressure (P < .0001), and eGFR (P < .0001), as well as a trend toward improved diastolic blood pressure response among patients managed with staged bilateral intervention (P = .0589). CONCLUSION Primary RA-PTAS for atherosclerotic RVD was associated with low peri-procedural morbidity and mortality but only modest early improvements in blood pressure and renal function. Results from ongoing prospective trials are needed to assess the long term outcomes associated with RA-PTAS and clarify its role in the management of atherosclerotic RVD.
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Affiliation(s)
- Matthew A Corriere
- Division of Surgical Sciences, Section on Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1095, USA
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Abstract
The prevalence of atherosclerotic renal artery stenosis (RAS) is more common than was previously thought, particularly in patients with known coronary, cerebrovascular, or peripheral vascular atherosclerosis. Clinical subsets in which RAS is more common include patients with uncontrolled hypertension, renal insufficiency, and/or sudden onset ("flash") pulmonary edema. Renal artery atherosclerosis progresses over time and is associated with loss of renal function regardless of medical therapy. Patients with symptomatic (hypertension, renal insufficiency, or flash pulmonary edema) and hemodynamically significant RAS are potential candidates for revascularization. The current standard of care is stent placement for aorto-ostial atherosclerotic lesions. Procedure success rates are very high (> or =95%), with infrequent major complication rates. Five-year primary patency rates are 80% to 85%, and secondary patency rates exceed 90%. The key element in managing patients with RAS is selecting those most likely to benefit, that is, those with blood pressure control, preservation or improvement of renal function, and control of flash pulmonary edema from renal revascularization. This article will highlight the anatomical features, physiologic parameters, and biomarkers that may be helpful in optimally selecting patients for renal artery revascularization.
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Affiliation(s)
- Christopher J White
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA 70121, USA.
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Talenfeld AD, Schwope RB, Alper HJ, Cohen EI, Lookstein RA. MDCT Angiography of the Renal Arteries in Patients with Atherosclerotic Renal Artery Stenosis: Implications for Renal Artery Stenting with Distal Protection. AJR Am J Roentgenol 2007; 188:1652-8. [PMID: 17515390 DOI: 10.2214/ajr.06.1255] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Use of distal protection in renal artery stenting entails overcoming challenges unique to renal artery anatomy. We used 3D image reconstruction to review high-spatial-resolution MDCT angiographic data to better characterize the anatomy of stenotic renal arteries. MATERIALS AND METHODS A total of 218 abdominal MDCT angiograms from a single tertiary care referral center were reviewed. The subjects were 108 patients who had 127 arteries with more than 50% ostial atherosclerotic renal artery stenosis. Vessel analysis software was used to measure renal artery length, cross-sectional area, and maximum diameter. Differences between mean values for women and men and for left and right renal arteries were measured with a two-tailed Student's t test. RESULTS Significant differences for men and women were found in average maximum cross-sectional area distal to the point of stenosis (0.3 +/- 0.19 vs 0.23 +/- 0.09 cm2, p = 0.006) and the corresponding maximum diameter (6.9 +/- 1.7 vs 6.1 +/- 1.1 cm2, p = 0.003). Average lengths of the main renal artery did not differ significantly for men and women. Differences for the left and right main renal arteries were found in minimum area (i.e., area of maximum stenosis, 0.08 +/- 0.04 vs 0.06 +/- 0.03 cm2, p = 0.03), area proximal to the bifurcation (0.26 +/- 0.11 cm2 vs 0.23 +/- 0.07 cm2, p = 0.02), and length (38.5 +/- 12.6 vs 48.7 +/- 16.2 mm, p = 0.0002). CONCLUSION Significant anatomic differences exist between the left and right renal arteries, between the renal arteries in men and those in women, and from one person to the next. Many of these differences are relevant to the design and use of distal protection devices in stenting of the renal arteries.
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Affiliation(s)
- Adam D Talenfeld
- Division of Interventional Radiology, Mount Sinai Medical Center, One Gustave L. Levy Pl., Box 1234, New York, NY 10029, USA
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Renal artery stenting slows the rate of renal function decline. J Vasc Surg 2007; 45:726-31; discussion 731-2. [DOI: 10.1016/j.jvs.2006.12.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Accepted: 12/07/2006] [Indexed: 11/18/2022]
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Bates MC, Rashid M, Campbell JE, Stone PA, Broce M, Lavigne PS. Factors Influencing the Need for Target Vessel Revascularization After Renal Artery Stenting. J Endovasc Ther 2006; 13:569-77. [PMID: 17042665 DOI: 10.1583/06-1861.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To provide additional insight into factors that may be associated with the need for target vessel revascularization (TVR) following de novo renal artery stenting during long-term follow-up. METHODS A retrospective chart and database review was conducted to analyze the progress of all patients with de novo symptomatic renal artery stenosis who underwent stent-supported angioplasty under the auspices of the Single Operator, Single Center, Renal Stent Retrospective Study (SOCRATES). The records review identified 782 patients who were enrolled in the study between 1993 and 2004; after excluding 34 (4.5%) patients (lost to follow-up or inadequate data), 748 consecutive patients (412 women; mean age 70.7+/-9.7 years, range 37-92) were suitable for longitudinal analysis. The need for TVR was based on strict clinical criteria (> or =20% rise in serum creatinine, worsening hypertension, and/or recurrent flash pulmonary edema), and all patients underwent multidisciplinary evaluation before stenting and during follow-up. RESULTS Follow-up spanned a mean 45.8+/-26.5 months. TVR was needed in 88 (10.03%) of 877 arteries and was best predicted by patient age < or =67 years (OR 2.91, p=0.0001), stent diameter < or =5.0 mm (OR 2.31, p=0.001), solitary functioning kidney (OR 2.01, p=0.048), history of lower extremity peripheral artery disease (OR 1.87, p=0.008), and antecedent history of stroke (OR 1.73, p=0.026). CONCLUSION Renal artery stenting appears to be durable, with only 10% of stented arteries requiring TVR during clinically-based long-term follow-up. Arteries with a final stent diameter < or =5.0 mm were more than twice as likely to need TVR, as were patients with a solitary kidney. The authors acknowledge that clinical recurrence is not a surrogate for ultrasound surveillance after renal artery stenting, so prospective controlled trials will be needed to determine risk factors for restenosis.
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Affiliation(s)
- Mark C Bates
- Vascular Center of Excellence, Charleston Area Medical Center, West Virginia School of Medicine Charleston Division, West Virginia, USA.
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Henry M, Henry I, Polydorou A, Rajagopal S, Lakshmi G, Hugel M. Renal angioplasty and stenting: long-term results and the potential role of protection devices. Expert Rev Cardiovasc Ther 2006; 3:321-34. [PMID: 15853605 DOI: 10.1586/14779072.3.2.321] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Renal angioplasty and stenting have become the first treatments to be proposed to patients presenting with renal artery stenosis. The immediate technical success rate is high, with a low complication rate and good long-term patency. In most reports, renal stenting has been proven to improve blood pressure. However, despite good immediate- and long-term results, postprocedural deterioration of renal function is a concern, and may occur after renal artery angioplasty and stenting in 20 to 40% of patients, which limits the immediate benefits of this technique. Of the causes of this deterioration in renal function, atheroembolism seems to play an important role. Contrary to earlier beliefs that atheroembolization is not an issue during percutaneous catheter interventions, there is now mounting evidence that distal atherosclerotic debris commonly embolizes from lesions in many vascular territories during percutaneous interventions. Atheroembolism seems to be the root cause of many procedural complications wherever atherosclerotic lesions are treated. Distal embolization was first demonstrated in saphenous vein grafts and now, clinical data are proving that similar embolization and distal-organ complications also occur during catheter treatment in certain native coronary lesions, carotid stenting and renal artery stenting, demonstrating the role and efficacy of protection devices to reduce the incidence of end-organ complications. The same protection devices (protection balloon and filters) utilized for coronary or carotid procedures may be used to protect the kidney from atheroembolism. In this review, the authors discuss recently published data concerning the techniques and results of renal angioplasty and stenting procedures performed under protection, and evaluate the benefits of this technique on renal function and its role in the future. Indications for this technique need to be discussed.
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Affiliation(s)
- Michel Henry
- Cabinet de Cardiologie, 80 rue Raymond Poincaré, 54000, Nancy, France.
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Edwards MS, Craven BL, Stafford J, Craven TE, Sauve KJ, Ayerdi J, Geary RL, Hansen KJ. Distal embolic protection during renal artery angioplasty and stenting. J Vasc Surg 2006; 44:128-35. [PMID: 16828436 DOI: 10.1016/j.jvs.2006.03.022] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Accepted: 03/08/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Percutaneous renal artery angioplasty and/or stenting (RA-PTAS) is increasingly being used as an alternative to surgery for renal artery revascularization. Unfortunately, renal function responses after RA-PTAS appear to be inferior to those observed after surgical revascularization both in terms of improving and preventing deterioration of renal function postintervention. Atheroembolism during RA-PTAS has been postulated as a potential cause for the disparate results. Strategies to limit the occurrence of atheroembolism, such as the use of distal embolic protection (DEP) systems, may result in improved outcomes after RA-PTAS. METHODS All RA-PTAS procedures performed with DEP (using a commercially available temporary balloon occlusion and aspiration catheter) between October 2003 and July 2005 were reviewed. Glomerular filtration rate (eGFR) was estimated preintervention and 4 to 6 weeks postintervention using the abbreviated Modification of Diet in Renal Disease formula. Renal function and hypertension response rates as well as procedural data were classified and reported according to American Heart Association guidelines. Renal function improvement and deterioration were defined as a 20% increase and decrease in eGFR, respectively, compared with preoperative values. Continuous and categoric data were analyzed using paired t tests and repeated measures linear models. RESULTS DEP was used in 32 RA-PTAS procedures in 15 women and 11 men with a mean age of 71 years. All patients were hypertensive, 24 (92%) had renal insufficiency, and the mean preintervention degree of renal artery stenosis was 79%. Immediate technical success was achieved in 100% of RA-PTAS cases. Mean pre- and postintervention serum creatinine and eGFR values were 1.9 vs 1.6 mg/dL (P < .001) and 37 vs 43 mL/min/1.73 m(2) (P < .001), respectively. Renal function was defined as improved after 17 (53%) of 32 procedures and worsened in none (0%). CONCLUSIONS RA-PTAS using DEP resulted in 4- to 6-week postintervention renal function results approximating those of surgical revascularization. These data suggest that DEP use may prevent renal function harm during RA-PTAS as a result of atheroembolism and warrant further investigation.
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Affiliation(s)
- Matthew S Edwards
- Department of General Surgery, Section on Vascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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Abstract
As a result of the many different potential locations to be treated, it is still difficult to evaluate the indications for efficacy and safety of non-coronary percutaneous transluminal angioplasty (PTA) and stenting versus surgical methods, such as endarterectomy or bypass grafts. This paper reviews pertinent data published in the last 5-10 years and gives an overview of the main peripheral minimally invasive vascular interventional fields.
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König K, Gellermann J, Querfeld U, Schneider MBE. Treatment of severe renal artery stenosis by percutaneous transluminal renal angioplasty and stent implantation: review of the pediatric experience: apropos of two cases. Pediatr Nephrol 2006; 21:663-71. [PMID: 16520954 DOI: 10.1007/s00467-006-0010-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2004] [Revised: 09/30/2005] [Accepted: 10/04/2005] [Indexed: 11/27/2022]
Abstract
The clinical course of two children with mid-aortic syndrome and renal artery stenosis (RAS) who suffered from severe arterial hypertension is described. Hypertension was uncontrollable by antihypertensive medication and was managed by percutaneous transluminal renal angioplasty (PTRA) with stent implantation. The pediatric experience with PTRA is limited, and there are only few cases reported with additional stent implantation. Complications of these procedures are well known from experience with adult patients. However, since surgical revascularization may be technically difficult especially in small children, PTRA with or without stenting should be considered as a valuable treatment option in pediatric RAS.
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Affiliation(s)
- Kai König
- Department of Pediatric Nephrology, Charité University Hospital, Otto-Heubner-Centrum für Kinder- und Jugendmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463-654. [PMID: 16549646 DOI: 10.1161/circulationaha.106.174526] [Citation(s) in RCA: 2177] [Impact Index Per Article: 120.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Affiliation(s)
- Christopher J White
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA 70121, USA.
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,⁎Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.02.024] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Wilson DB, Edwards MS, Ayerdi J, Hansen KJ. Surgical Management of Atherosclerotic Renal Artery Disease. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50030-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sahin S, Cimşit C, Andaç N, Baltacioğlu F, Tuğlular S, Akoğlu E. Renal artery stenting in solitary functioning kidneys: Technical and clinical results. Eur J Radiol 2006; 57:131-7. [PMID: 15951146 DOI: 10.1016/j.ejrad.2005.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Revised: 04/25/2005] [Accepted: 05/09/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the clinical and technical results of renal artery stenting for the treatment of renovascular hypertension and renal failure in patients with solitary functioning kidney. MATERIALS AND METHODS Fifteen patients with solitary functioning kidney underwent renal artery stenting and were followed up for 12-60 months. Before the procedures, systolic and diastolic blood pressures and serum creatinine levels were measured and the number of antihypertensive drugs was recorded and followed up after stenting. In case of restenosis, either in-stent percutaneous transluminal renal angioplasty or stent-in-stent placement was performed. RESULTS Primary technical success rate was 100%. One lesion was nonostial while 14 were ostial. Primary patency rates were 100% for 6 months, 92.3% for 12 months, and 69.2% for 24 months. The secondary patency rate at 24 months was 100%. The differences between the baseline and postprocedural values of systolic blood pressures, diastolic blood pressures and the number of antihypertensive drug were statistically significant (P < 0.05), except the values of serum creatinine. Hypertension was cured in 1 (6.7%) patient, improved in 4 (26.6%) and stabilized in 10 (66.7%) patients. Renal function improved in 9 (60%), stabilized in 4 (26.6%), and deteriorated in 2 (13.4%) patients. Minor complication rate was 13.4% and major complication rate was 13.4%. CONCLUSION Revascularization of renal artery stenosis using stent in solitary functioning kidneys is a safe and efficient procedure with high primary technical results, low restenosis rates and acceptable complication rates. It has an improving and controlling effect on blood pressure and renal functions.
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Affiliation(s)
- Sinan Sahin
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Hospital, Department of Radiology, Istanbul, Turkey
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Bessias N, Sfyroeras G, Moulakakis KG, Karakasis F, Ferentinou E, Andrikopoulos V. Renal Artery Thrombosis Caused by Stent Fracture in a Single Kidney Patient. J Endovasc Ther 2005; 12:516-20. [PMID: 16048386 DOI: 10.1583/05-1542.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To report a case of incomplete expansion, fracture, and thrombosis of a stent in the renal artery. CASE REPORT A 47-year-old man with right renal artery occlusion underwent direct stenting of the left renal artery using a balloon-expandable stent. Completion angiography showed satisfactory patency of the vessel although the stent was not fully expanded in its central segment. The patient received 5000 units of heparin during the procedure, but no additional anticoagulant or antiplatelet therapy in the peri/postinterventional period. Twenty-five days later, he presented with acute renal insufficiency and uncontrolled hypertension. Angiography revealed in-stent thrombosis and collateral flow in the distal segment of the left renal artery. He underwent an aortorenal bypass, which salvaged the kidney. The stent, after removal from the vessel, was fractured and not completely expanded. CONCLUSIONS Incomplete expansion and fracture of the stent associated with insufficient antiplatelet therapy produced in-stent thrombosis. Collateral flow prevented kidney necrosis.
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Affiliation(s)
- Nikolaos Bessias
- Department of Vascular Surgery, Red Cross Hospital of Athens, Greece
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