Percutaneous Transluminal Renal Artery Angioplasty Research Articles

Atherosclerotic renovascular disease: a clinical practice document by the European Renal Best Practice (ERBP) board of the European Renal Association (ERA) and the Working Group Hypertension and the Kidney of the European Society of Hypertension (ESH).

Atherosclerotic renovascular disease (ARVD) is the most common type of renal artery stenosis. It represents a common health problem with clinical presentations relevant to many medical specialties and carries a high risk for future cardiovascular and renal events, as well as overall mortality. The available evidence regarding the management of ARVD is conflicting. Randomized controlled trials failed to demonstrate superiority of percutaneous transluminal renal artery angioplasty (PTRA) with or without stenting in addition to standard medical therapy compared with medical therapy alone in lowering blood pressure levels or preventing adverse renal and cardiovascular outcomes in patients with ARVD, but they carried several limitations and met important criticism. Observational studies showed that PTRA is associated with future cardiorenal benefits in patients presenting with high-risk ARVD phenotypes (i.e. flash pulmonary oedema, resistant hypertension or rapid loss of kidney function). This clinical practice document, prepared by experts from the European Renal Best Practice (ERBP) board of the European Renal Association (ERA) and from the Working Group on Hypertension and the Kidney of the European Society of Hypertension (ESH), summarizes current knowledge in epidemiology, pathophysiology and diagnostic assessment of ARVD and presents, following a systematic literature review, key evidence relevant to treatment, with an aim to support clinicians in decision making and everyday management of patients with this condition.

Abstract 545: Predictors Of Complications And Extended Length Of Stay Following Percutaneous Transluminal Renal Artery Angioplasty

Background: Patients with Renal Artery Stenosis (RAS) who fail medical management may be evaluated for Percutaneous Transluminal Renal Artery Angioplasty (PTRA). Comorbidities increasing the risk of complications following PTRA have not been explored well. Methods: Patients undergoing PTRA for RAS were sampled using National Inpatient Sample (NIS) Database. Demographics, length of stay (LOS), and comorbidities were gathered using ICD-10 codes. Complications included heart failure, myocardial infarction, cardiac arrest, major bleeding, stent thrombosis, renal artery dissection/embolism, aortic dissection/rupture and atheroembolism. Extended LOS (ELOS) was defined as LOS greater than 4 days. Univariate and multivariate logistic regression analyses were used to identify predictors for complications and ELOS. Results: 517 patients underwent PTRA. Most prevalent comorbidities were peripheral vascular disease, coronary artery disease and dyslipidemia. On multivariate analysis, comorbidities significant for predicting major complications were end-stage renal disease, chronic liver disease, heart failure and coagulable disorders whereas comorbidities significant for predicting ELOS were chronic lung disease, chronic liver disease, diabetes and coagulable disorders (Figure 1). Conclusion: As we continue to identify the ideal candidates for PTRA, it is important to consider the comorbidities that predispose these patients to increased periprocedural complications and ELOS.

Outcomes and Efficacy of Percutaneous Transluminal Renal Artery Angioplasty with Stent in Patients with Atherosclerotic Renal Artery Stenosis

Outcomes and Efficacy of Percutaneous Transluminal Renal Artery Angioplasty with Stent in Patients with Atherosclerotic Renal Artery Stenosis

MON-167 TRANSPLANT RENAL ARTERY STENOSIS AS A POTENTIAL COMPLICATION AFTER KIDNEY TRANSPLANTATION FROM DONOR WITH MOYAMOYA DISEASE: A CASE REPORT

Moyamoya disease is a rare chronic cerebrovascular disorder with progressive stenosis of intracranial internal carotid arteries and their proximal branches resulting in the development of severe collateral circulations and associated with a high risk of stroke. Moyamoya disease may have extracranial manifestations such as coronary artery fistulas and stenosis, cardiac valve stenosis, congenital heart disease, and renal artery stenosis. Although organs from donors with Moyamoya disease are considered safe for transplantation, there are few reports describing the use of the organs. Here, I described the unfortunate case of kidney transplant (KT) recipient who received transplanted kidney from donor with Moyamoya disease presented with early transplant renal artery stenosis (TRAS). A 42-year-old Thai male with end-stage renal disease from unknown cause underwent KT from a 32-year-old Thai male deceased donor who was firstly diagnosed Moyamoya disease with catastrophic cerebral infarction. The KT was complicated by delayed graft function and his kidney function recovered after 2 sessions of hemodialysis. The maintenance immunosuppressive drugs included cyclosporine, mycophenolate mofetil and prednisolone. Routine Doppler ultrasound examination of transplanted kidney was done at postoperative day 7 without abnormal findings. Three months after KT, he presented with kidney allograft dysfunction, hypertension and volume overload. His serum creatinine increased from 2.08 to 5.53 mg/dL. The Cyclosporine level was within normal range. Serum BK virus and cytomegalovirus were undetectable. Kidney biopsy pathology showed diffuse ischemic tubular atrophy and interstitial edema and fibrosis without evidence of rejection. Repeat Doppler ultrasound examination of transplanted kidney revealed good transplant perfusion with a turbulent flow and a peak systolic velocity > 2 m/s at mid to distal main renal artery. Magnetic resonance angiography of transplant renal artery was also confirmed the stenosis. TRAS was diagnosed and percutaneous transluminal renal artery angioplasty (PTRA) was done without stent placement. His kidney function improved with serum creatinine of 2.53 mg/dL 2 weeks after the procedure. Then his serum creatinine increased again to the level of 5.52 mg/dL two months after the 1st procedure. PTRA was done again with renal artery stent placement. Finally, his kidney function recovered with serum creatinine of 1.72 mg/dL six month s after the 2nd procedure. Figure 2. To the best of my knowledge, this is the 1st reported case of PTRAS in KT recipient who received transplanted kidney from donor with Moyamoya disease. I believe that transplant physicians should continue using organs from donors with Moyamoya disease but must be aware of the possible extracranial complications like in my case.

Kidney autotransplantation for the treatment of renal artery occlusion after endovascular aortic repair: a case report

BackgroundUnintentional renal artery occlusion after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm remains one of the most unfavorable complications. Renal salvage options include percutaneous transluminal renal artery angioplasty (PTRA) and open hepatosplenorenal bypass. However, the usefulness of kidney autotransplantation (AutoTx) remains unclear.Case presentationA 76-year-old woman with a right solitary kidney attributable to a left renal thromboembolism had previously undergone EVAR with a stent graft for an infrarenal aortic aneurysm, which led to ostial occlusion of the right renal artery. In addition, she had undergone PTRA and stenting. Two days before admission, she developed leg edema and hypertension, leading her to visit the hospital. Her serum creatinine level was 2.4 (baseline, 1.0) mg/dL. Acute kidney injury due to renal artery in-stent restenosis was suspected; re-angioplasty was attempted on day 2 of hospitalization, but was unsuccessful. Her renal function did not improve and anuria persisted; thus, hemodialysis was initiated on the same day. The right kidney size (8.6 cm) was preserved relative to her body size, with only mild cortical atrophy. Doppler ultrasonography and mercaptoacetyltriglycine scintigraphy revealed minimal but significant perfusion of the right kidney. Therefore, we considered that kidney perfusion was sustained and renal function could be reversed. On day 25 of hospitalization, right kidney AutoTx to the right iliac fossa was performed to reestablish adequate renal perfusion and reverse the need for dialysis. Soon after the procedure, the patient started passing urine. Her renal function improved; her serum creatinine level decreased to 1.0 mg/dL on day 33 of hospitalization. Hemodialysis was discontinued after the surgery. Zero-hour kidney biopsy showed only mild tubular injury, with neither tubular necrosis nor glomerular abnormalities.ConclusionsKidney AutoTx can be performed for patients with renal artery in-stent occlusion after unsuccessful PTRA who previously underwent EVAR. Our case showed successful recovery of renal function nearly 1 month after renal artery occlusion, indicating that revascularization should be considered even if it is delayed, as the kidney might be perfused through collateral circulation.

A case of percutaneous transluminal renal artery angioplasty for renovascular hypertension with multiple renal arteries

A case of percutaneous transluminal renal artery angioplasty for renovascular hypertension with multiple renal arteries

Renal Autotransplantation at Three Academic Institutions in Turkey

Objective: The objective of this study is to present the experience of 3 institutions performing renal autotransplantation (RAT) and to discuss surgical techniques employed and the results in the light of the medical literature. Materials and Methods: A total of 14 patients (11 male and 3 female) with a mean age of 47 ± 8 years (35-61 years), who underwent RAT procedure at 3 different institutions between October 2006 and November 2014, in Turkey, were evaluated retrospectively. Indications for RAT procedure are ureteral avulsion, renal artery aneurysm and intimal dissection caused by percutaneous transluminal renal artery angioplasty (PTRA). Twelve patients with ureteral avulsion, 1 patient with renal artery aneurysm and 1 patient with intimal dissection caused by PTRA were followed-up for 103 months. Seven (50%) open and 7 (50%) laparoscopic nephrectomies were performed. Nine patients (64.3%) were right-sided and 5 patients (35.7%) were left-sided. Complications of grade III and above as per Clavien-Dindo classification were assessed. Results: Mean time from injury to RAT was 21.2 ± 40.1 days. However, 5 (35.7%) patients were treated on the same day of the injury. As per Clavien-Dindo classification, 2 (14.2%) grade IVa and 1 (7.1%) grade IIIa complications were reported. However, no significant correlation was observed between the complications and graft loss regarding type and side of the nephrectomy performed (p = 0.462 and p = 0.505, respectively) and timing of the intervention (p = 0.692). Conclusion: RAT is a safe procedure in combination with minimally invasive laparoscopic technique in carefully selected patients; however, it requires expertise and proficiency in laparoscopy, reconstructive urology and transplantation. Nevertheless RAT should be considered as the last resort, when other modalities fail.

Short- and mid-term results of balloon angioplasty for renal artery fibromuscular dysplasia

This study aimed to evaluate short- and mid-term outcomes of percutaneous transluminal renal artery angioplasty (PTRA) in patients with symptomatic renal artery stenosis caused by renal artery fibromuscular dysplasia (RAFMD). Retrospective analysis of 22 patients with RAFMD who were performed PTRA between 2006 and 2012. These patients underwent PTRA due to poorly controlled hypertension. Pre- and post-PTRA blood pressure (BP) measurements and renal function were evaluated. Freedom from events (restenosis, repeat intervention, renal failure, and recurrent hypertension) was investigated using life table analysis. Twenty-two patients (54.5% women, mean age 39.2 years) with 24 renal arteries underwent PTRA. The technical success rate was 100%. The mean systolic BP decreased from 155.9 ± 14.7 to 138.3 ± 9.41 mmHg (P = 0.00004), and the mean diastolic BP decreased from 99.0 ± 11.5 to 88.0 ± 7.19 mmHg (P = 0.0043). Rates of freedom from recurrent or worsening hypertension, defined by >140 mmHg systolic BP and >90 mmHg diastolic BP, were 89.4, 89.4, 81.3, and 71.1% at 1, 2, 3, and 4 years, respectively. Restenosis-free rates were 90.0, 83.6, 73.4, and 61.9%, respectively. No patient underwent repeat intervention and renal failure. PTRA is a durable modality for treating RAFMD with favorable short- and mid-term clinical outcomes.

Mitochondria-targeted therapies for acute kidney injury.

Acute kidney injury (AKI) is a serious clinical condition with no effective treatment. Tubular cells are key targets in AKI. Tubular cells and, specifically, proximal tubular cells are extremely rich in mitochondria and mitochondrial changes had long been known to be a feature of AKI. However, only recent advances in understanding the molecules involved in mitochondria biogenesis and dynamics and the availability of mitochondria-targeted drugs has allowed the exploration of the specific role of mitochondria in AKI. We now review the morphological and functional mitochondrial changes during AKI, as well as changes in the expression of mitochondrial genes and proteins. Finally, we summarise the current status of novel therapeutic strategies specifically targeting mitochondria such as mitochondrial permeability transition pore (MPTP) opening inhibitors (cyclosporine A (CsA)), quinone analogues (MitoQ, SkQ1 and SkQR1), superoxide dismutase (SOD) mimetics (Mito-CP), Szeto-Schiller (SS) peptides (Bendavia) and mitochondrial division inhibitors (mdivi-1). MitoQ, SkQ1, SkQR1, Mito-CP, Bendavia and mdivi-1 have improved the course of diverse experimental models of AKI. Evidence for a beneficial effect of CsA on human cardiac ischaemia-reperfusion injury derives from a clinical trial; however, CsA is nephrotoxic. MitoQ and Bendavia have been shown to be safe for humans. Ongoing clinical trials are testing the efficacy of Bendavia in AKI prevention following renal artery percutaneous transluminal angioplasty.

Educational Exhibit Abstract No. 422 - Diagnosis and treatment of renovascular hypertension in children

Learning Objectives To describe and illustrate with examples the techniques and unique management challenges in diagnosing and treating renovascular hypertension in children. Background Renovascular hypertension (RVH) is an uncommon yet important and potentially curable cause of secondary hypertension in children, accounting for approximately 10% of cases. The management of RVH in the pediatric population presents specific challenges related to both the size and expected growth of the involved vessels as well as the often bilateral, subsegmental, and intrarenal distribution of disease. A variety of laboratory and imaging criteria are useful in establishing a diagnosis of RVH, however catheter angiography augmented by direct renal vein renin measurement remains the test of choice. Likewise, percutaneous transluminal renal artery angioplasty remains a highly effective front line treatment option with the goal of reducing or eliminating the need for medical therapy and avoiding complex surgical revascularization. Clinical Findings/Procedure Details The clinical pathway for the diagnosis of RVH will be discussed including the relevant pre-procedural non-invasive imaging and laboratory tests aimed at excluding more common causes of secondary hypertension. The angiographic features of RVH will be illustrated in multiple cases, with an emphasis on findings unique to pediatric patients. The diagnostic relevance and proper technique for direct renal vein renin sampling will be described. Angiographic technique and equipment particularly useful for imaging and successful treatment of the pediatric population will be reviewed. Additional cases will illustrate the uncommon occurrence of angioplasty failure requiring stent placement as well as unexpected causes of hypertension encountered during angiography. Conclusion and/or Teaching Points Interventional radiologists play a pivotal role in the diagnosis and treatment renovascular hypertension in children. Knowledge of the unique features of this disease and technical challenges in the pediatric population is critical in providing potentially curative endovascular therapy.

Response of blood pressure after percutaneous transluminal renal artery angioplasty and stenting

To evaluate the short and intermediate term outcome of percutaneous transluminal renal artery angioplasty (PTRA) and stenting particularly on blood pressure (BP) control and renal function and to evaluate predictors of poor BP response after successful PTRA and stenting. We conducted a prospective analysis of all patients who underwent PTRA and stenting in our institute between August 2010 to September 2012. A total number of 86 patients were underwent PTRA and renal stenting. Selective angiography was done to confirm at least 70% angiographic stenosis. The predilatation done except few cases with critical stenosis, direct stenting was done in the rest of cases. All patients received aspirin 325 mg orally, and clopidogrel 300 mg orally within 24 h before the procedure. Heparin was used as the procedural anticoagulant agent. Optimal results with TIMI-III flow obtained in all cases. Following stent placement, aspirin 150 mg orally once daily was continued for a minimum of 12 mo and clopidogrel 75 mg orally once daily for at least 4 wk. The clinical, radiological, electrocardiography, echocardiography and treatment data of all patients were recorded. The BP measurement, serum creatinine and glomerular filtration rate (GFR) were recorded before the procedure and 1 and 6 mo after PTRA. A total of 86 patients were included in the study. The mean age of study population was 55.87 ± 11.85 years old and 67 (77.9%) of patients were male. There was a significant reduction in both systolic and diastolic BP at 1 mo after the procedure: 170.15 ± 20.10 mmHg vs 146.60 ± 17.32 mmHg and 98.38 ± 10.55 mmHg vs 89.88 ± 9.22 mmHg respectively (P = 0.0000). The reduction in BP was constant throughout the follow-up period and was evident 6 mo after the procedure: 144.23 ± 18.19 and 88.26 ± 9.79 mmHg respectively (P = 0.0000). However, no improvement in renal function was observed at any time during the follow-up period. After multivariate analysis, we found male sex, low GFR (< 60 mL/min) and higher baseline mean BP as a poor predictors of successful outcome on BP response after PTRA and stenting. The PTRA and stenting can be considered as an effective therapeutic intervention for improving BP control with minimal effect on renal function. The male sex, higher baseline BP and low GFR are associated with poor BP response after successful PTRA and stenting.

Renal dynamic imaging for the treatment assessment of renal artery angioplasty and stenting in patients with atherosclerotic renal artery stenosis

Objective To investigate the value of renal dynamic imaging with 99Tcm-DTPA on the evaluation and prediction of the outcome after percutaneous transluminal renal artery angioplasty and stenting (PTRAS) in patients with atherosclerotic renal artery stenosis (ARAS).Methods Seventy-six patients with unilateral ARAS underwent PTRAS successfully.All the patients received baseline renal dynamic imaging within 2 weeks before the surgery and follow-up imaging 6 months after PTRAS.GFR ( per 1.73 m2 of body surface area) of kidney with ARAS was measured with the Gates method.ARAS was classified as mild (50％-69％),moderate (70％-89％),and severe ( ≥90％ ) stenosis according to the results of renoarteriography before the surgery.GFR was graded as Ⅰ ( GFR≥30 ml · min -1 ),Ⅱ ( 15 ml · min -1 ≤GFR ＜30 ml · min -1 ) and Ⅲ ( GFR ＜ 15 ml · min-1 ),on the baseline dynamic imaging.Blood pressure was also measured before and after the surgery.The t test,x2 test,Fisher exact test and multiple logistic regression analysis were used for statistical analysis with SPSS 13.0.Results The baseline GFR of kidney with mild and moderate ARAS was significant higher than that with severe stenosis ( (26.79 ± 15.34) vs ( 19.48 ±11.56) ml · min - 1,t =2.262,P =0.027 ).The blood pressure was improved in 32％ (24/75),and not changed in 68％ (51/75) of patients.Improvement of blood pressure was observed in 39.62％ (21/53) of patients with a baseline GFR≥ 15 ml · min-1,and in 13.64％ (3/22) of patients with a baseline GFR ＜15 ml · min - 1 (x2 =4.825,P =0.028 ).Using multivariate analysis,baseline GFR ≥ 15 ml · min - 1 was the only predictor of blood pressure improvement ( OR =0.465,P =0.032 ).GFR in kidney with ARAS was improved in 22.37％ ( 17/76),stable in 68.42％ (52/76),and worse in 9.21％ (7/76) of patients.The 33.33％ (8/24) and 17.65％ (9/51) of patients with and without blood pressure improvement,respectively,achieved GFR improvement.However,the difference was not statistically significant ( Fisher exact test,P =0.081 ).Conclusion Renal dynamic imaging with 99Tcm-DTPA is a useful method for the evaluation and prediction of the therapeutic effect of PTRAS in patients with ARAS. Key words: Renal artery ; Atherosclerosis; Angioplasty; Radionuclide imaging; DTPA

Impact of endovascular treatment of atherosclerotic renal artery stenosis on endothelial function and arterial blood pressure.

Renovascular disease may cause arterial hypertension and decreases renal function, which both impair endothelial function. Endothelial function, a surrogate marker for cardiovascular risk, can be assessed non-invasively by ultrasound. The aim of this study was to investigate the impact of percutaneous transluminal renal artery angioplasty (PTRA) with stenting on endothelial function and arterial blood pressure in patients with renal artery stenosis (RAS). Flow mediated dilatation of the brachial artery, flow velocities and shear stress were measured with high resolution ultrasound in 24 hypertensive patients with renal artery stenosis prior and one day after revascularization by PTRA with stenting. Endothelial-independent brachial dilatation was measured after application of nitroglycerin. Endothelial-dependent dilatation improved from 2.4±0.9% to 6.1±1.4% (P=0.03), whereas endothelial-independent dilatation did not change after PTRA. Endothelial-dependent reactive hyperemic blood flow increased from 195±40 mL/min to 536±94 mL/min (P=0.0008), whereas endothelial-independent hyperemia did not increase after revascularization. After PTRA, shear stress at rest decreased from 37±11 to 23±3 dyne/cm² (P<0.0001), and reactive hyperemic shear stress increased from 89±29 to 107±12 dyne/cm² (P=0.014). The impact of PTRA on arterial blood pressure resulted in a mean decrease of 21±5 mmHg in systolic pressure (P<0.0001), of 9±2 mmHg in diastolic pressure (P=0.03), and of 14±5 mmHg in peripheral pulse pressure (P=0.0003), respectively. Endovascular treatment of renovascular disease improves endothelial function and decreases in resting shear stress.

Late Outcomes of Endovascular and Open Revascularization for Nonatherosclerotic Renal Artery Disease

Conclusion: In patients with nonatherosclerotic renal artery disease (NARAD), open revascularization results in superior 1- and 5-year outcomes compared with endovascular management. Summary: Fibromuscular dysplasia and Takayasu arteritis are the most common etiologies of NARAD leading to hypertension. Open or endovascular revascularization is preferred over medical management alone in patients with severe hypertension associated with NARAD. Percutaneous transluminal angioplasty (PTA) is generally considered first-line therapy for fibromuscular disease, whereas open revascularization is generally thought to be the best treatment for patients with Takayasu arteritis. The purpose of this report was to evaluate long-term outcomes of endovascular and open treatment of NARAD. This was a retrospective review of 55 patients (47 women), with a mean age of 40 years. Underlying disease processes included Takayasu arteritis in 31 patients and fibromuscular dysplasia in 24. Open revascularization was compared with renal artery PTA, with and without stenting, for primary, primary assisted, and secondary patency rates as well as blood pressure, antihypertensive medication requirements, renal function, and mortality. Among the 79 renal artery interventions performed were 59 aortorenal bypasses (16 ex vivo), 3 visceral-to-renal artery bypasses, 5 nephrectomies, and 12 endovascular percutaneous revascularizations, 4 of which included stent placement. There were no procedural deaths. Mean follow-up was 75 months. Rates of primary patency at 1, 3, and 5 years for any intervention were 87%, 75% and 75%, respectively. Primary, primary assisted, and secondary patency rates were 92%, 86%, and 86%, respectively. Primary patency rates for endovascular interventions at 1, 3, and 5 years were 73%, 49%, and 49%. Primary assisted/secondary patency rates for endovascular interventions were 83%, 83%, and 83% at 1, 3, and 5 years. At 1, 3, and 5 years, primary patency rates for open revascularization were 91%, 80%, and 80%. Primary assisted/secondary patency rates for open interventions at 1, 3 and 5 years were 94%, 87%, and 87%, respectively. Open and endovascular interventions both resulted in improvements in blood pressure and the number of antihypertensive medications compared with preintervention values (all P < .05). Revascularization also improved serum creatinine levels and estimated glomerular filtration rate (both P < .05). The 5- and 10-year actuarial survival rates were 94% and 78%, respectively. Comment: The authors demonstrated open and endovascular intervention can be safe and effective in management of renal artery-mediated hypertension and renal dysfunction associated with NARAD. The patients are not randomized, and any conclusions are somewhat weakened by the study design, but in general, the data indicate primary open revascularization, when compared with endovascular intervention, results in superior outcome with respect to patency with equivalent safety. The authors' conclusion is that open revascularization should be considered selectively as first-line of therapy for NARAD in the young patient with moderate to complex renal artery disease. This conclusion is clearly suggested but not confirmed by the data.

Endovascular and Open Revascularization for Nonatherosclerotic Renal Artery DiseaseEndovascular and Open Revascularization for NARAD

Sung Wan Ham, MD; S. Ram Kumar, MD; Bonnie R. Wang, BA; Vincent L. Rowe, MD; Fred A. Weaver, MD, MMMObjective: To evaluate the long-term outcome of endovascular and open treatment for nonatherosclerotic renal artery disease (NARAD).Design: Retrospective review.Setting: Academic institution.Patients: Fifty-five patients (47 women; mean age, 40 years) with NARAD. Underlying disease included Takayasu arteritis in 31 and fibromuscular dysplasia in 24.Interventions: Open revascularization and renal artery percutaneous transluminal angioplasty with or without stenting.Main Outcome Measures: Primary, primary assisted, and secondary patency rates; blood pressure; antihypertensive medication requirements; renal function; and mortality.Results: Seventy-nine renal interventions were performed, including 59 aortorenal bypass (16 ex vivo), 3 visceral-renal bypass, and 12 endovascular (8 percutaneous transluminal angioplasty and 4 stent placements) procedures, and 5 nephrectomies. There were no in-hospital deaths. During a mean follow-up of 75 months, 1-, 3-, and 5-year primary patency rates for any intervention were 87%, 75%, and 75%, respectively; primary assisted/secondary patency rates were 92%, 86%, and 86%, respectively. Endovascular interventions at 1, 3, and 5 years had primary patency rates of 73%, 49%, and 49%, respectively, and primary assisted/secondary patency rates of 83%, 83%, and 83%, respectively. For open revascularization, 1-, 3-, and 5-year primary patency rates were 91%, 80%, and 80%, respectively; primary assisted/secondary patency rates were 94%, 87%, and 87%, respectively. For both interventions, blood pressure and the number of antihypertensives used were reduced compared with preintervention values (all P < .05). Serum creatinine level and estimated glomerular filtration rate were also improved after revascularization (both P < .05). There were 6 deaths. Five- and 10-year actuarial survival rates were 94% and 78%, respectively.Conclusions: Endovascular and open management of NARAD confers long-term benefit for blood pressure, renal function, renal artery/graft patency, and survival. Open revascularization results in superior 1- and 5-year outcomes compared with endovascular management and provides the most durable outcome for NARAD.

Late Outcomes of Endovascular and Open Revascularization for Nonatherosclerotic Renal Artery Disease

To evaluate the long-term outcome of endovascular and open treatment for nonatherosclerotic renal artery disease (NARAD). Retrospective review. Academic institution. Fifty-five patients (47 women; mean age, 40 years) with NARAD. Underlying disease included Takayasu arteritis in 31 and fibromuscular dysplasia in 24. Open revascularization and renal artery percutaneous transluminal angioplasty with or without stenting. Primary, primary assisted, and secondary patency rates; blood pressure; antihypertensive medication requirements; renal function; and mortality. Seventy-nine renal interventions were performed, including 59 aortorenal bypass (16 ex vivo), 3 visceral-renal bypass, 12 endovascular (8 percutaneous transluminal angioplasty and 4 stent placements) procedures, and 5 nephrectomies. There were no in-hospital deaths. During a mean follow-up of 75 months, 1-, 3-, and 5-year primary patency rates for any intervention were 87%, 75%, and 75%, respectively; primary assisted/secondary patency rates were 92%, 86%, and 86%, respectively. Endovascular interventions at 1, 3, and 5 years had primary patency rates of 73%, 49%, and 49%, respectively, and primary assisted/secondary patency rates of 83%, 83%, and 83%, respectively. For open revascularization, 1-, 3-, and 5-year primary patency rates were 91%, 80%, and 80%, respectively; primary assisted/secondary patency rates were 94%, 87%, and 87%, respectively. For both interventions, blood pressure and the number of antihypertensives used were reduced compared with preintervention values (all P<.05). Serum creatinine level and estimated glomerular filtration rate were also improved after revascularization (both P<.05). There were 6 deaths. Five- and 10-year actuarial survival rates were 94% and 78%, respectively. Endovascular and open management of NARAD confers long-term benefit for blood pressure, renal function, renal artery/graft patency, and survival. Open revascularization results in superior 1- and 5-year outcomes compared with endovascular management and provides the most durable outcome for NARAD.

Effect of baseline glomerular filtration rate on renal function following stenting for atherosclerotic renal artery stenosis

Percutaneous transluminal renal artery angioplasty and stenting (PTRAS) is one treatment option for atherosclerotic renal artery stenosis (ARAS). However, factors predicting the outcome remain controversial. This study investigated the effect of the baseline glomerular filtration rate (GFR) on renal function after PTRAS in patients with ARAS. Patients who underwent PTRAS due to significant ARAS (luminal narrowing > or = 60%) were enrolled. The patients were divided into control (n = 57; estimated GFR (eGFR) > or = 60 ml/min/1.73 m(2)) and chronic renal failure (CRF) groups (n = 53; eGFR < 60 ml/min/1.73 m(2)), according to the baseline eGFR. The mean age at the time of PTRAS was 62 +/- 9 years, and the mean duration of follow-up was 50 +/- 26 months. There was a significant decrease in eGFR after PTRAS in the control group, whereas the CRF group showed no significant change in eGFR. The percentage change in eGFR was negatively correlated with the baseline eGFR (r = -0.274, p = 0.004). Multivariate linear regression revealed that only baseline eGFR predicted the change in eGFR (p = 0.032). PTRAS was more effective at preserving renal function in patients with moderately impaired renal function. Thus, baseline GFR may indicate the expected renal function outcome after PTRAS.

Outcome after endovascular revascularization of atherosclerotic renal artery stenosis

With an aging population, more patients might be treated for atherosclerotic renal artery stenosis (ARAS). The goal of this treatment is to achieve a dialysis-free life or a well-controlled blood pressure with reduced risks of cardiovascular complications. To analyze the clinical outcome of percutaneous transluminal renal artery angioplasty without stenting (PTRA) or with stenting (PTRS) for ARAS at one center. The study group comprised 152 patients who underwent 203 PTRA/PTRS. All had hypertension, and 45% had azotemia. A retrospective collection of baseline and postprocedural number of antihypertensive drugs, blood pressure, and serum creatinine were analyzed during a follow-up of 3-18 months. Technical success rate was 95%, and clinical benefit was seen in 63% of patients. Complications included a 30-day mortality rate of 1.5%, a total complication rate of 35%, and major adverse events in 13%. The major adverse events were highly related to azotemia. Major adverse events within 30 days, with permanent disability, were seen in 5% and almost exclusively in patients with moderate or severe renal impairment. A subgroup analysis of 28 patients with renal duplex resistive index (RI) pre-PTRA/S and 6 months' follow-up showed a benefit of PTRA/PTRS in 17 (68%) of the 25 patients with RI <80 and in all three (100%) of the patients with RI >or=80. Endovascular treatment of ARAS has an excellent technical success rate, with a clinical improvement rate of >60%. However, it is associated with a considerable complication rate. Serious complications are seen mainly in azotemic patients. Predictors of clinical response could not be identified. Renal duplex RI is questioned as a predictor of clinical outcome.

Multiple inflammatory aneurysms: A rare complication of idiopathic inflammatory aortitis

A 64-year-old man, with a left primary nephrectomy, was referred for evaluation of a para-umbilical hernia. On examination, a large expansile abdominal mass was noted. Computerised tomography (CT) demonstrated (i) multiple diffuse aneurysmal dilatations of the thoraco-abdominal aorta, (ii) peripheral arterial aneurysms and (iii) stenoses of the coeliac, superior mesenteric and right renal arteries. Persistently elevated inflammatory markers (ESR: 22 and CRP: 44) and the absence of atherosclerotic risk factors, including a smoking history, suggested an underlying diagnosis of idiopathic inflammatory aortitis. This was supported by fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) which demonstrated increased tracer activity in the root, ascending, proximal arch and descending aorta. Initial treatment to suppress the active inflammatory component of the disease involved steroid therapy. Open surgical or endovascular repair of the aortic aneurysms was however deemed unfeasible. Percutaneous transluminal renal artery angioplasty (PTRA) of his sole renal artery was attempted; unfortunately this was unsuccessful resulting in renal arterial occlusion with subsequent infarction of the right kidney leaving the patient haemodialysis dependent. This case highlights the clinical variability and complications of severe idiopathic inflammatory aortitis and the risk in performing PTRA in patients with complex anatomy of the aorta.

La sténose radique de l’artère rénale : une complication inhabituelle de la radiothérapie

Introduction Renal artery stenosis represented 1 to 5% of all arterial hypertensions and is the leading cause of secondary hypertension. Renovascular hypertension is more common among women less than 30 years old (fibrodysplasia, 33%) and men older than 50 years old (66% atherosclerosis). Other causes are rare, especially radiation-induced renal artery stenosis. Materials and methods We report the case of Mr. D., 49 years old, with severe high blood pressure (230/125 mmHg) seven years after abdominal radiotherapy for Hodgkin's disease. Echo-Doppler was performed and found a subocclusive right ostial renal artery stenosis probably radiation-induced taking into account the history of the patient. Renal angiography confirmed this diagnosis and percutaneous transluminal renal artery angioplasty was performed with a final acceptable result (residual stenosis < 50%). Discussion Radiation-induced renal artery stenosis is rare (0.5/1000 to 1%). Most of the cases are proximal and the median time from radiation to referral is nine years. Radiation-induced nephritis disease was often referred to occurrence high blood pressure after abdominal radiotherapy but various data shows that radiation can also cause damage to larger vessels sizes (such as renal arteries) induced by atherosclerosis radiation. Patients should be successful treated by percutaneous intervention, as demonstrated by Fakhouri et al. [Am J Kidney Dis 38 (2001) 302–309] in a study of 11 patients. Conclusion This case shows that radiation-induced renal artery stenosis may occur many years after initial treatment, and patients developing severe arterial hypertension after abdominal radiation should be investigated for renal artery stenosis.