scholarly journals To Stent or Not to Stent? This is the Renal Artery Stenosis Question

2014 ◽  
Vol 6 (1) ◽  
pp. 1-2
Author(s):  
Michael Doumas ◽  
Konstantinos Tziomalos ◽  
Vasilios G. Athyros
Keyword(s):  
Blood Pressure ◽  
Renal Function ◽  
Renal Artery ◽  
Renal Artery Stenosis ◽  
Medical Therapy ◽  
Clinical Benefit ◽  
Optimal Medical Therapy ◽  
Renal Angioplasty ◽  
Renal Artery Stenting

A few days ago (Nov 18, 2013) the results of the large prospective 􀀃􀀇􀀑􀀉􀀌􀀐􀀕􀀇􀀒􀀈􀀔􀀍􀀇􀀑􀀁 􀀅􀀔􀀓􀀈􀀐􀀎􀀊􀀒􀀁 􀀌􀀏􀀁 􀀆􀀊􀀏􀀇􀀍􀀁 􀀂􀀓􀀋􀀊􀀑􀀐􀀖 􀀒􀀈􀀍􀀊􀀑􀀐􀀓􀀌􀀈􀀁 􀀄􀀊􀀒􀀌􀀐􀀏􀀒􀀁 􀀗􀀃􀀅􀀆􀀂􀀄􀀘􀀁 􀀓􀀑􀀌􀀇􀀍 were presented and published. CORAL enrolled 947 participants who had atherosclerotic renal artery stenosis (ARAS), 􀀂 60% and either uncontrolled systolic hypertension despite treatment with 􀀂 2 anti-hypertensive drugs or stage 3 chronic kidney disease (CKD) [1]. CORAL randomly assigned patients to medical therapy plus renal-artery stenting or medical therapy alone. The median follow-up period was 43 months and the primary endpoint was a composite of death from cardiovascular disease (CVD) or renal causes, myocardial infarction (MI), stroke, congestive heart failure, progression of renal insufficiency, or need for renal replacement therapy. Results showed that the addition of renal-artery stenting to thorough multifactorial medical therapy did not contribute a significant clinical benefit with respect to the prevention of CVD events or renal function deterioration. Adverse CVD or renal events occurred in 35.1% of patients who received stenting and 35.8% of those on medical therapy alone (p=0.58) [1]. Thus, the authors concluded that renal artery stenting was not superior to optimal medical therapy alone for moderately severe ARAS [1]. The results of CORAL have a direct impact on clinical practice questioning the need for renal artery stenting in patients managed with optimal medical therapy. The message seems to be very simple. If patients have ARAS and high blood pressure, they need a very aggressive comprehensive medical therapy before considering any interventional procedure. A recent meta-analysis investigated CVD outcome in patients with ARAS treated either with renal angioplasty or antihypertensive drug therapy [2]. Pooled data from 5 studies (n=1,159 patients) showed that during the 2-year follow-up there were no significant clinical outcome differences between angioplasty and medical therapy [2], both in patients with or without CKD. In another study [3] it was shown that patients with ARAS and normal or near normal renal function (creatinine 􀀁2.0 mg/dl) can be safely treated with effective drug treatment, with a small decrease in GFR. For patients who have atherosclerotic MI, stroke or renal impairment, renal artery stenting may further reduce blood pressure and delay the deterioration or even improve renal function [3]. The Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial (n =867) [4], although criticised by some for methodological issues [5], results showed that there were no meaningful clinical benefit from revascularization in patients with ARAS; however considerable risks were present [4]. On the other hand, in patients with renovascular hypertension due to fibromuscular dysplasia (RAFMD) and/or the combination of RAFMD with ARAS, angioplasty is the method of choice and has favourable short- and long-term CVD and renal clinical outcomes [6]. The take away message from all the above is that prior trials showed similar results in mild ARAS; this study established the futility of stenting for a higher severity (moderate severity) of the disease. Substantially severe forms of ARAS will probably have to undergo renal angioplasty with stenting, especially when flash pulmonary oedema occurs [7-9].

Effect of Percutaneous Transluminal Renal Angioplasty on Absolute Split Renal Function in Patients with Renovascular Hypertension. Influence of Age and Other Parameters

1993 ◽  
Vol 60 (1) ◽  
pp. 27-33
Author(s):  
M. Takeda ◽  
Y. Katayama ◽  
K. Saito ◽  
T. Tsutsui ◽  
T. Komeyama ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Renal Function ◽  
Renal Artery ◽  
Renal Artery Stenosis ◽  
Plasma Renin ◽  
Artery Stenosis ◽  
Renal Angioplasty ◽  
Split Renal Function ◽  
Percutaneous Transluminal Renal Angioplasty ◽  
Percutaneous Transluminal

Tc99m-dimercaptosuccinic acid renal uptake (DMSA uptake) was examined to assess the changes in split renal function following percutaneous transluminal renal angioplasty (PTRA) in 9 patients with a total of 12 renal artery stenoses and renovascular hypertension (RVH). The results were studied with respect to age, degree of renal artery stenosis, and renal vein renin ratio (RVRR) before PTRA. Although the degree of renal artery stenosis, systolic blood pressure, and peripheral blood plasma renin activity were improved 3 months after PTRA, neither the DMSA uptake of the affected kidneys nor that of the contralateral kidneys improved. Although restenosis occurred during the long follow-up period in one patient, DMSA uptake did not change in parallel with the degree of stenosis or RVRR. The degree of improvement in DMSA uptake, blood pressure, and plasma renin activity after PTRA in patients aged under 70 years was significantly higher than that in patients 70 years or older. Good improvement of renal function was attained in a 4-year-old boy, despite the fact that split renal function prior to PTRA was so poor that nephrectomy had been considered instead of PTRA. These results suggest that several factors before PTRA, such as DMSA uptake, degree of renal artery stenosis, and RVRR, are not absolutely predictive of results after PTRA, and that the effect of PTRA on blood pressure and renal function is greater in younger patients.

scholarly journals Renal Artery Stenting Associated With Improvement in Renal Function and Blood Pressure Control in Long-Term Follow-Up

2016 ◽  
Vol 41 (3) ◽  
pp. 278-287 ◽  
Author(s):  
Krzysztof Milewski ◽  
Wojciech Fil ◽  
Piotr Buszman ◽  
Małgorzata Janik ◽  
Wojciech Wanha ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Renal Function ◽  
Renal Artery ◽  
Blood Pressure Control ◽  
Pressure Control ◽  
Renal Artery Stenting ◽  
Long Term Follow Up

Renovascular Hypertension and Stenosis

2018 ◽  
Author(s):  
J. Gregory Modrall
Keyword(s):  
Blood Pressure ◽  
Renal Function ◽  
Renal Artery ◽  
Renal Artery Stenosis ◽  
Renovascular Hypertension ◽  
Radiographic Finding ◽  
Artery Stenosis ◽  
Clinical Predictors ◽  
Ischemic Nephropathy ◽  
Renal Artery Stenting

Renal artery stenosis (RAS) may present clinically as an incidental radiographic finding in an asymptomatic patient, or it may be the etiology of renovascular hypertension or ischemic nephropathy. Incidental RAS should be treated medically. The available clinical trial data suggest that medical management is the primary treatment for presumed renovascular hypertension. Renal artery stenting should be reserved for patients who fail medical therapy. When renal artery stenting is contemplated for presumed renovascular hypertension or ischemic nephropathy, clinical studies suggest that there are clinical predictors of outcomes that may be useful in identifying patients with a higher probability of a favorable clinical response to stenting. Clinical predictors of a favorable blood pressure response to renal artery stenting include (1) a requirement of four or more antihypertensive medications, (2) preoperative diastolic blood pressure greater than 90 mm Hg, and (3) preoperative clonidine use. The only clinical predictor of improved renal function with stenting is the rate of decline of estimated glomerular filtration rate (eGFR) in the weeks prior to stenting. Patients with a more rapid decline in eGFR have a higher probability of improved renal function after stenting compared with those with relatively stable eGFR prior to stenting. Finally, surgical renal artery revascularization remains a viable option but is usually reserved for younger, fit patients with unfavorable anatomy for stenting. Pediatric renovascular disease responds poorly to endovascular therapy and requires a surgical plan to address both renal artery stenoses and concomitant abdominal aortic coarctation if present. Renal artery stenosis in pediatric patients is best treated with reimplantation of the renal artery or interposition grafting using the autogenous internal iliac artery as a conduit. This review contains 39 references, 15 figures, and 3 tables. Key Words: chronic kidney disease, hypertension, renal artery stenosis, renovascular, stenting

P3570Bilateral renal artery stenting is effective method for the treatment of uncontrolled hypertension and renal function

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J Uzokov ◽  
A L Alyavi ◽  
B A Alyavi ◽  
S A Iskhakov ◽  
D D Payziev
Keyword(s):  
Blood Pressure ◽  
Renal Function ◽  
Serum Creatinine ◽  
Renal Artery ◽  
Uncontrolled Hypertension ◽  
Renal Artery Stenting ◽  
Group I ◽  
Group Ii ◽  
Bilateral Stenting

Abstract Background Renal artery (RA) stenosis is one of the main causes of severe uncontrolled primary hypertension among population. Aim of the study was to investigate effectiveness of stent replacement in renal arteries and influence it on renal function in uncontrolled hypertensive patients (UHP) with pharmacotherapies. Methods 86 consecutive UHP with renal etiology confirmed by angiography were enrolled in this study. Mean age of the patients was 43.2±12.5 years (aged 31–59 years, male=46%). Blood pressure, serum creatinine, microalbuminuria were assessed at baseline and after the intervention and during the follow-up for statistics. Mean follow-up was 2.0±1.0 years. Results Total of 128 hemodynamically significant renal artery stenosis were treated by implanting stents in all 86 patients. Among them in 42 patients were performed bilateral stenting (Group I) and 44 patients unilateral stenting (Group II). Systolic and diastolic blood pressure (SBP, DBP) decreased in both groups during the follow-up, however it was noted that only SBP were decreased significantly in Group I (unilateral stenting) whilst reduction in DBP not significantly when compared to Group II. Mean reduction in SBP was from 165.0±20.5 mmHg to 130.4±14.0 mmHg in Group I vs. from 158.0±22.0 to 135.0±15.0 mmHg in Group II (P=0.003 when compared two groups) and in DBP was from 95.0±11.2 mmHg to 83.4±8.0 mmHg in Group I vs. from 93.0±10.0 to 82.0±7.5 mmHg in Group II (P>0.05 when compared two groups). Serum creatinine levels were reduced from 123.0±49.0 μmol/l to 85.4±30.6 μmol/l in Group I vs 116.8±51.2 μmol/l to 86.9±35.5 μmol/l (P<0.05 when compared two groups). Significantly reduction in MAU were noted in both groups (P<0.05) but when compared two groups there were no significant changes in reduction. Conclusion Renal artery stenting is effective method for the treatment of UHP and may improve outcomes of the patients. Bilateral stenting seems to be more effective in blood pressure and serum creatinine control in UHP.

Sirolimus-Eluting versus Bare-Metal Low-Profile Stent for Renal Artery Treatment (GREAT Trial): Angiographic Follow-up after 6 Months and Clinical Outcome up to 2 Years

2007 ◽  
Vol 14 (4) ◽  
pp. 460-468 ◽  
Author(s):  
Markus Zähringer ◽  
Marc Sapoval ◽  
Peter M. T. Pattynama ◽  
Claudio Rabbia ◽  
Claudio Vignali ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Renal Function ◽  
Adverse Events ◽  
Renal Artery ◽  
Renal Artery Stenosis ◽  
Bare Metal ◽  
Low Profile ◽  
Drug Eluting ◽  
Major Adverse Events

Purpose: To evaluate the patency of sirolimus-eluting stents (SES) compared to bare-metal stents (BMS) in the treatment of atherosclerotic renal artery stenosis (RAS). Methods: Between November 2001 to June 2003, 105 consecutive symptomatic patients (53 men; mean age 65.7 years) with RAS were treated with either a bare-metal (n=52) or a drug-eluting (n=53) low-profile Palmaz-Genesis peripheral stent at 11 centers in a prospective nonrandomized trial. The primary endpoint was the angiographic result at 6 months measured with quantitative vessel analysis by an independent core laboratory. Secondary endpoints were technical and procedural success, clinical patency [no target lesion revascularization (TLR)], blood pressure and antihypertensive drug use, worsening of renal function, and no major adverse events at 1, 6, 12, and 24 months. Results: At 6 months, the overall in-stent diameter stenosis for BMS was 23.9%±22.9% versus 18.7%±15.6% for SES (p=0.39). The binary restenosis rate was 6.7% for SES versus 14.6% for the BMS (p=0.30). After 6 months and 1 year, TLR rate was 7.7% and 11.5%, respectively, in the BMS group versus 1.9% at both time points in the SES group (p=0.21). This rate remained stable up to the 2-year follow-up but did not reach significance due to the small sample. Even as early as 6 months, both types of stents significantly improved blood pressure and reduced antihypertensive medication compared to baseline (p<0.01). After 6 months, renal function worsened in 4.6% of the BMS patients and in 6.9% of the SES group. The rate of major adverse events was 23.7% for the BMS group and 26.8% for the SES at 2 years (p=0.80). Conclusion: The angiographic outcome at 6 months did not show a significant difference between BMS and SES. Renal artery stenting with both stents significantly improved blood pressure. Future studies with a larger patient population and longer angiographic follow-up are warranted to determine if there is a significant benefit of drug-eluting stents in treating ostial renal artery stenosis.

scholarly journals Clinical response scores to predict blood pressure and renal function improvement following renal artery stenting for atherosclerotic renal artery stenosis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Kablak-Ziembicka ◽  
A Roslawiecka ◽  
R Badacz ◽  
A Sokolowski ◽  
P Musialek ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Logistic Regression ◽  
Renal Function ◽  
Renal Artery ◽  
Renal Artery Stenosis ◽  
Predictive Models ◽  
Artery Stenosis ◽  
Atherosclerotic Renal Artery Stenosis ◽  
Baseline Serum ◽  
Kidney Length

Abstract Background It is little known about predictors of systolic (SBP) and diastolic (DBP) blood pressure or renal function (eGFR) improvement in patients with atherosclerotic renal artery stenosis (ARAS) undergoing stent-assisted angioplasty (PTA). Therefore, we aimed to build a prediction scores that would indicate characteristics of patient subsets with ARAS most likely to have clinical improvement following PTA. Methods 201 patients who underwent PTA for ARAS (2003–2018) were categorized as eGFR or SBP/DBP responders based on eGFR increase of ≥11 ml/min/1.73m2, decrease of SBP ≥20mmHg and DBP ≥5mmHg at 12-months following PTA. The remaining patients were classified as non-responders. The performance of logistic regression models were evaluated by basic decision characteristics. Continuous data have been transformed into binary coding with help of operating characteristic (ROC) curve. Predictive models have been constructed for each followed by construction of predictive models in each of 3 categories. Results Logistic regression analysis showed that: baseline SBP&gt;145 mmHg, DBP &gt;82 mmHg, previous myocardial infarction and Renal-Aotric-Ratio &gt;5.1 were independent influencing factors of SBP response, with relative risk percentage shares of 69.8%; 12.1%; 10.9%; and 7.2%, respectively (sensitivity: 82%, specificity: 86.3%, positive (PPV):82% and negative (NPV) predictive values: 86.3%). The DBP decrease prediction model included baseline SBP &gt;145 mmHg and DBP &gt;82 mmHg, the ARAS progression, index kidney length &gt;106 mm, and bilateral PTA with respective shares of 35.0%; 21.8%; 18.2%; 13.3% and 11.8%. (sensitivity: 76%, specificity: 77.8%, PPV: 80.7% and NPV: 72.6%). The eGFR increase was associated with baseline serum creatinine &gt;122 μmol/L but eGFR greater than 30 ml/min/1.73m2, index kidney length &gt;98 mm, end-diastolic velocity in index renal artery, renal resistive index &lt;0.74, and requirement for &gt;3 BP medications, with respective shares of 24.4%; 24.4%; 21.2%; 15% and 15% (sensitivity: 33.3%, specificity: 93.5%, PPV: 65.6% and NPV: 78.9%). Conclusions Current study identified clinical characteristics of patients who most likely to respond to PTA for ARAS. The sutability of the score should be verified in a prospective cohort of patients referred to PTA of ARAS Funding Acknowledgement Type of funding source: None

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