Transluminal vascular stent for ostial atherosclerotic renal artery stenosis

doi:10.1016/S0140-6736(95)92283-0

The Lancet

Volume 346, Issue 8976, 9 September 1995, Pages 672-674

https://doi.org/10.1016/S0140-6736(95)92283-0 Get rights and content

Abstract

We implanted transluminal stents in 24 hypertensive patients with a critical atherosclerotic ostial renal artery stenosis (28 arteries). Immediate revascularisation was successful in all. Follow-up angiography at 6 months, available in 18 patients, revealed restenosis twice. In another patient restenosis was suspected and confirmed by angiography at 2 months. Hence, the total restenosis rate was 3 of 19 patients (16%) and 3 of 23 arteries (13%). Two patients developed renal insufficiency due to cholesterol embolism. In the remaining 22 patients renal function improved (n=8) or stabilised (n=14). Although all had to resume antihypertensive treatment, blood pressure normalised in 15 patients, improved in one, remained unchanged in five and worsened in one.

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Cited by (179)

Hemodynamic Measurements for the Selection of Patients With Renal Artery Stenosis: A Systematic Review
2017, JACC: Cardiovascular Interventions
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.
Massive rhabdomyolysis: An uncommon complication of cholesterol embolization syndrome
2013, Annales Francaises d'Anesthesie et de Reanimation
Nous rapportons le cas d’un patient de 79 ans, aux antécédents d’athérosclérose, avec des lésions ischémiques des orteils et de livedo des membres inférieurs. La présence de plaques athéromateuses ulcérées aortiques sur l’angioscanner faisait évoquer des embolies spontanées de cholestérol. Un geste endovasculaire aortique était néanmoins réalisé pour tenter de stabiliser les plaques molles. Au décours immédiat apparaissaient des myalgies et une impotence fonctionnelle totale des membres inférieurs, de nouvelles lésions ischémiques au niveau anale et génitale et des orteils, un livedo étendu à la paroi abdominale, et une rhabdomyolyse massive entraînant une insuffisance rénale anurique avec hyperkaliémie aiguë traitée par épuration extrarénale avec anticoagulation par citrate. Une corticothérapie orale était instaurée, permettant une régression des lésions cutanées et une récupération partielle de la fonction rénale. La biopsie cutanée réalisée avant l’intervention endovasculaire montrait la présence d’emboles de cholestérol.
A 79-year-old man with atherosclerosis presented blue toes and livedo reticularis. The patient had eroded aortic atheromatous plaques, and cholesterol embolization syndrome was suspected. An endovascular technique to exclude sources of cholesterol emboli was however performed. The patient immediately presented with severe muscle pain and total functional disability of lower limbs, new ischemic lesions of toes, anal and genital necrosis, and a livedo extended up to the abdomen. A massive rhabdomyolysis occurred associated with acute kidney injury and hyperkaliemia treated by continuous renal replacement therapy with regional citrate anticoagulation. Steroids have been introduced and renal function improved. Cholesterol crystals were also found on a skin biopsy, performed before endovascular procedure.
Baseline inflammatory status and long-term changes in renal function after percutaneous renal artery stenting: A prospective study
2013, International Journal of Cardiology
Citation Excerpt :
In this prospective registry of patients with very high prevalence of clinically symptomatic vascular disease, we failed to find an overall significant effect of renal artery stenting of atherosclerotic RAS on serum creatinine levels at 6 months. This is in agreement with previous data showing either no benefit on median creatinine levels [12,13], or a minor one in larger series [14–16]. According to an American Heart Association document, however, a slowed decline in renal function suffices to claim a benefit from renal revascularization [17], and some recent studies have accordingly reported a higher incidence of serum creatinine stabilization over time in patients treated with renal stenting [18,19].
To investigate a possible independent predictive role of systemic inflammation markers on renal function after renal artery stenting.
An elevated baseline serum creatinine has previously been shown to be the strongest predictor of improved renal function after percutaneous renal artery stenting. The inflammatory system is implicated in every stage of chronic kidney disease, and we hypothesized an additional value of markers of systemic inflammation in predicting response after renal artery stenting.
This single center, prospective study includes 62 consecutive patients with chronic kidney disease at stage ≥ 3 or resistant hypertension who underwent stent placement for 74 angiographically significant atherosclerotic renal lesions. Inflammatory markers, including serum C-reactive protein (CRP), erythrocyte sedimentation rate, and white blood cell count were determined prior to renal angioplasty and related to changes in renal function at follow-up.
Six-month clinical follow up was completed in 57 patients. Overall, median serum creatinine concentration exhibited a non significant reduction from 1.40 mg/dl (quartiles: 1.20, 1.75 mg/dl) at baseline to 1.30 mg/dl (quartiles: 1.1, 1.55 mg/dl) at 6 months (p = 0.17). Significant multivariate independent predictors of decreased creatinine included higher baseline serum creatinine levels (adjusted OR per quartile increment, 2.5 [1.3 to 4.7], p = 0.004) and lower C-reactive protein levels (adjusted OR per quartile increment 0.39 [0.19 to 0.82], p = 0.013).
Patients with higher serum creatinine and lower CRP derive the most benefit from renal artery stenting.
Renal artery stenosis: Prevalence of, risk factors for, and management of in-stent stenosis
2013, American Journal of Kidney Diseases
Citation Excerpt :
Reflecting the lack of prospective studies using angiographic surveillance for the diagnosis of in-stent stenosis, the true incidence of in-stent stenosis is unclear. Reported rates vary widely from 6%-60%, as summarized in Table 1.51-78 Studies that used duplex ultrasonography to screen for in-stent stenosis report rates of 13%-39%.
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.
Randomized trials in angioplasty and stenting of the renal artery: Tabular review of the literature and critical analysis of their results
2012, Annals of Vascular Surgery
As the incidence of hypertension (HTN) continues to rise, finding the optimal treatment of this multifactorial disease is critical. Renal artery stenosis (RAS) is a known etiology for HTN and is associated with declining renal function. Other than medications, the original gold standard for treatment of HTN from RAS was with an open surgical revascularization or nephrectomy. Since then, endovascular interventions for RAS have been reported to be technically possible, but their efficacy over medications or surgery has yielded conflicting results in case series and randomized trials. This tabular review summarizes the results of randomized trials that compared the outcomes of endovascular renal artery interventions with nonendovascular techniques (including medical and surgical treatments) for the treatment of HTN and renal dysfunction. Based on these data, the strengths and weaknesses of individual trials are critically analyzed to better define the methods to identify and treat patients with RAS.
Clinical efficacy of percutaneous renal revascularization with stent placement in hypertension among patients with atherosclerotic renovascular diseases
2011, Journal of Cardiovascular Disease Research
Aim: The aim was to assess the effect of renal angioplasty with stent on systolic, diastolic, and mean arterial blood pressure (MAP) in awake and sleep time with ambulatory blood pressure (ABP) monitoring (Holter monitoring). Materials and Methods Patients with angiographically proven atherosclerotic renal artery stenosis (RAS) were referred to the Angiography Department of Imam Hospital for intervention during a 1-year period from June 2008 to December 2009. Primary stent placement was attempted by a single operator in 27 severe RAS cases although 1 case was omitted from the study because of technical failure. Pre- and postprocedure creatinine levels, ejection fraction (EF), history of diabetes mellitus (DM), and ABP were obtained. Twenty-six (17 men, 9 women; average age, 62.6 years; age range, 90-21 years) consecutive patients participated in the study. Results: All patients had severe hypertension resistant to multiple medications; 10 patients had impaired renal fonction (serum creatinine level greater than 130 μmol/L). A total of 3 (11.5%) patients had congestive heart failure, and 10 (37.7%) were diabetic. Hypertension was cured in 1 (4%) patient, had improved in 23 (88.4%) patients, and had failed to respond to treatment in 2 (7.6%). Serum creatinine decreased significantly from 1.46 ± 0.89 to 1.35 ± 0.61 mg/dL (P < 0.05). Conclusion: Percutaneous transluminal angioplasty for atheromatous RAS rarely "cures" hypertension, but improved blood pressure control is often achieved.

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Transluminal vascular stent for ostial atherosclerotic renal artery stenosis

Abstract

J Vasc Interv Radiol

Am J Kidney Dis

Percutaneous transluminal renal angioplasty in renovascular hypertension due to atheroma or fibromuscular dysplasia

N Engl J Med

Regional registry of dialysis and transplantation of Piedmont, Italy

Nephrol Dial Transplant

A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease

N Engl J Med