Renal Angioplasty Research Articles

#5555 TAKAYASU ARTERITIS IN THE TIME OF SARS-COV-2

Abstract Background and Aims SARS CoV 2 infection is characterized by pulmonary, cardiovascular, neurological and other complications. New onset hypertension after SARS Cov 2 infection was observed in various studies with an unclear mechanism. Vessel inflammation is a common finding in these patients. Case A young woman (24 years old) referred to our Unit for high blood pressure levels appeared few days after SARS COVID 2 infection. She had a positive familiar history of hypertension. A 24 hours blood pressure monitoring confirmed hypertension and the patient was treated with a beta-blocker and referred to the nephrologist. Physical examination was negative and peripheral pulses were palpable. Blood pressure was 150/90 mmHg without significative discrepancy (<10 mmHg) between right and left arm and between upper and lower limbs. Carotid-femoral and carotid-radial pulse wave velocity was in the upper limit of the normal range (9.8 and 8.0 m/sec respectively), renal function was preserved (serum creatinine 0.6 mg/dl, eGFR 154 ml/min) and proteinuria was 450 mg/die. C-reactive protein was 13 mg/L. Complement components C3 and C4 as well as IgG and anti-neutrophil cytoplasmic antibody (ANCA) levels were in the normal range. IgA and IgM were slightly elevated and anti-nuclear antibody (ANA) levels were 1:160. TSH was in the normal range. Patient was switched to calcium channel blockers and a screening to exclude secondary hypertension was performed. Hormonal profile showed hypersecretion of cortex and medullary adrenal gland (high renin and aldosterone, plasma and urinary cortisol, and epinephrine levels). Patient was treated with ACE inhibitor and showed an optimal blood pressure profile. Abdominal-Chest CT angiography detected no increase in adrenal gland dimension. Conversely, a left renal artery stenosis and a mild enlargement of the para-aortic tissue, suggestive of a retroperitoneal fibrosis, was described (Figure 1). A Doppler ultrasound examination confirmed a high systolic peak velocity in left renal artery and a low resistive index in the left kidney. According to the diagnosis of renal fibrosis, patient was treated with oral prednisone at a dosage of 1 mg/Kg/BW. Three months later, Doppler ultrasound and CT were materially unchanged. After a case revision and a negative evidence of inflammation at PET-FDG examination, the Takayasu Arteritis diagnosis was formulated and the patient underwent left renal artery angioplasty. Oral prednisone was tapered and methotrexate was started. One month later blood pressure and Doppler ultrasound velocimetric parameters were normalized. Conclusion This case report suggests that Takayasu arteritis may occur after SARS COVID 2 infection.

#6682 RENAL ARTERY STENOSIS: A SINGLE CENTRE STUDY

Abstract Background and Aims Renal artery stenosis (RAS) is present from 1% to 5% in people affected by arterial hypertension and it is often associated with peripheral artery disease and coronary artery disease; as the matter of fact, it is commonly found in people undergoing cardiac catheterization (18-20%) or angiography for aorto-iliac and lower extremities diseases. The major cause of renal artery stenosis is an atherosclerotic lesion localized in the proximal segment or to the ostium. Clinical presentations are renovascular hypertension and ischemic nephropathy. The aim of the study is to define either endovascular treatment gives a significant benefit on renal function and blood pressure control, when associated to medical therapy. Method This is a retrospective study focused on patients who underwent renal artery angioplasty and stenting in the last ten years, from November 2011 to April 2021 in the Nephrology Department, at Sant'Andrea Hospital, La Spezia (Italy). The primary outcome was kidney function, while secondary outcomes were blood pressure and the number of antihypertensive drugs one year after the revascularization. Patients included in the study had uncontrolled and refractory arterial hypertension (PA ≥140/90 mmHg) and/or progressive worsening of renal function, secondary to bilateral or unilateral stenosis in one functional kidney, that was identified at the color-doppler ultrasound examination by a peak systolic velocity (PSV) >200 ml/min and an aortic-renal ratio >3,5. We found 36 patients who had these characteristics. They were all affected by chronic kidney disease (CKD) (mean±SD eGFR 25,3±15,3 ml/min/1,73 m2) equally divided into stage 3 (33%, eGFR 30-60 ml/min/1,73 m2), stage IV (31% eGFR 15-29 ml/min/1,73 m2) and stage V (36%, eGFR <15 ml/min/1,73 m2). Results Kidney function, measured as serum creatinine (SCr) (mg/dl), improved immediately after the revascularization (mean ± SD SCr after vs before 2,52 ± 1,61 vs 3,31 ± 2,47 mg/dl p<0.05), after 30 days (mean ± SD SCr after vs before creat. 2,36 ± 1,53 vs 3,19 ± 2,39 mg/dl p<0.05) and after one year (mean ± SD SCr after vs before creat. 2,04 ± 1,16 vs 2,99 ± 2,40 mg/dl p<0.05) (Fig. 1). Regarding arterial hypertension, a significant reduction of both systolic (SBP) and diastolic (DBP) blood pressure was detected in the subgroup of people under 75 years old (mean ± SD SBP after vs before, 144,62 ± 12,55 vs 168,18 ± 36,40 mmHg, p< 0,01; after one year vs before, 143,95 ± 21,10 vs 167,83 ± 38,16 mmHg, p<0.05) (mean ± SD DBP after vs before, 73,62 ± 9,62 vs 83,07 ± 21,75 mmHg, p< 0,05; after one year vs before 75,20 ± 9,02 vs 83,33 ± 23,10 mmHg, p = 0.07) (Fig. 2). The number of antihypertensive drugs dropped immediately after the angioplasty (mean ± SD tablets after vs before 2,28 ± 1,11 vs 3,21 ± 1,43, p<0.01), while after one year there was not a significant increase of therapy (mean ± SD tablets after one year vs before, 3,00 ± 1,41 vs 3,23 ± 1,42, p = 0,47), even if blood pressure was better controlled than before the procedure with the same amount of tablets (Fig. 3). Conclusion Although our population was quite small, we demonstrated the advantages of renal artery revascularization in atherosclerotic renovascular disease, as demonstrated by kidney function and blood pressure control. Our results contrast the larger studies considered, that found no relevant clinical benefit on renal function and incidence of major adverse cardiovascular and renal events by comparing patients treated with medical therapy alone or with medical therapy plus angioplasty. The different conclusions are probably due to our strict adhesion to the endovascular treatment indications, which consider the revascularization as the optimal strategy for a well-defined population.

TRANSLUMINAL ANGIOPLASTY OF THE RENAL ARTERIES IN PATIENTS WITH FIBROMUSCULAR DYSPLASIA

Objective: FMD is the second most frequent cause of renal artery stenosis (RAS) after atherosclerosis and can lead to hypertension. To cure or improve this renovascular hypertension, patient with fibromuscular dysplasia and renal artery stenosis undergo renal artery revascularization by percutaneous renal transluminal angioplasty (PTRA). Although this method has been performed for many years, there have been only few small size trials published. This retrospective single center study aimed to evaluate the rate of cured hypertension after PTRA. Design and method: We included all adult patients diagnosed with FMD who were seen in our referral center for hypertension management (Hôpital Européen Georges Pompidou, Paris) from January 2010 to March 2020. Blood pressure response was assessed at 3 month and one year. Primary outcome was one year cured hypertension rate in ambulatory measurement, secondary outcomes were improvement and complication rate. Results: Overall, 76 adult patients (87% female, mean age at enrollment 35.5 years) were included. FDM was multifocal in 74% and unisite in 68% of patients. AT baseline, mean day ambulatory blood pressure (dABP) was 141 ± 17/89 ± 14 mmHg under a mean of 2.3 ± 1.37 antihypertensive treatments. All patient underwent PTRA. Stent were inserted in 8 patients (10.5%) with residual stenosis after PTRA and in 8 patients (10.5%) with renal artery dissection, total complication rate was 18.4%. At one-year follow-up, mean dABP was 128 ± 12/78 ± 9 mmHg (p < 0.0001) with 1.1 ± 1.3 treatments (p < 0.0001). In total, 75% beneficiated from renal angioplasty: 31% were cured and 44% were improved. Cured hypertension was associated with low body mass index (BMI) (p = 0.017) and unisite FDM (p = 0.017) on a multivariable analysis. Conclusions: In patients with FMD, PTRA is associated with cured hypertension 31% of patients with renal artery FMD undergoing PRTA. Hypertension is more likely to be cured in patient with low BMI and multisite FMD. These results are to be put in perspective with a complication rate of 18.4%.

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.

Moyamoya disease presenting with tubular dysfunction in a child: pitfalls in diagnosing an atypical hyponatremic-hypertensive syndrome

BackgroundMoyamoya disease, a cause of pediatric stroke, has been shown to affect furthermore extra-cranial districts, mostly the kidney arterial site, resulting in steno-occlusive changes. Unilateral renal artery stenosis accounts for 8%-10% out of cases of renovascular hypertension in childhood, however it rarely underlies a hyponatremic-hypertensive syndrome (HHS).Case presentationWe describe an 18-month-old boy with a recent history of polyuria and polydipsia, who presented an acute febrile gastroenteritis with neurological impairment, severe dehydration, hyponatremia, hypokalemia, kidney tubular dysfunction, and elevated aldosterone and renin even with a normal blood pressure. Fluid and electrolytes correction was performed, with complete recovery. An abdominal ultrasound displayed a smaller right kidney. A brain magnetic resonance and an electroencephalogram did not show any relevant abnormalities. Five months later, the child experienced a left-side hemiparesis after a traumatic concussion, and a severe hypertension. A brain tomography documented a cerebral ischemia. Brain and kidney angiographic studies displayed puff of smoke findings of internal right carotid artery branches and a steno-occlusive pattern of right renal artery, respectively. Hence, moyamoya disease with HHS secondary to unilateral renal artery stenosis was diagnosed. After an unsuccessful antiplatelet and antihypertensive pharmacological treatment, the boy underwent a renal angioplasty and a cerebral STA-MCA bypass (direct superficial temporal artery-to-middle cerebral artery bypass), resulting in a significant improvement of both neurological and kidney disease.ConclusionsAlthough the association between unilateral renal artery stenosis and HHS has been previously shown, this is the first report of atypical HHS, with hypertension preceded by tubular dysfunction, recognized in the framework of moyamoya disease.

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.

A Case report of Resistant Hypertension due to Renal Artery Stenosis: Long Term Sufferings of a Middle-Aged Gentleman

Atherosclerotic renal artery stenosis is the leading cause of reno-vascular hypertension and is prevalent in elderly patients (over 65 years) and those with resistant hypertension. This article presents a case report of a 60-year-old gentleman who presented with resistant hypertension resulting in heart failure and significant morbidity. The patient's medical history included frequent hospitalizations with uncontrolled hypertension, flash pulmonary edema and heart failure. Despite multiple hospitalizations, the underlying cause of his condition remained unrecognized until further investigation revealed left sided renal artery stenosis as the culprit lesion. Successful renal artery angioplasty resulted in the resolution of the patient's high blood pressure and improvement of general well-being. This case highlights the potential for resistant hypertension due to renal artery stenosis to be overlooked, particularly in patients with multiple comorbidity. It is important to consider the possibility of renal artery stenosis in patients with uncontrolled blood pressure with recurrent pulmonary oedema, not responding to multiple anti-hypertensive drugs in the highest possible dose. Bangladesh J Medicine 2023; 34(2): 163-167

Renal Artery Stenosis Complicated with Primary Aldosteronism.

Primary aldosteronism (PA) is a typical example of low renin hypertension, whereas renal artery stenosis (RAS) is a classic form of high renin hypertension. PA and RAS occurring simultaneously in a patient is challenging to diagnose. We report a 32-year-old woman with a 12-year history of resistant hypertension. She was identified to have elevated plasma aldosterone and renin levels with normal aldosterone/renin ratio (ARR). Imaging examinations identified bilateral adrenal thickening and subtotal occlusion of the anterior segment of the left renal artery. Adrenal venous sampling was performed and indicated the existence of unilateral aldosterone over-secretion. It may suggest that even though RAS led to non-suppressed renin, adrenal venous sampling remains to be an applicable approach to establish the diagnosis of aldosterone-producing adenomas, although the diagnostic value of ARR may be compromised due to non-suppressed renin level. The patient underwent a two-stage treatment. First, stenosis of the left renal artery was dilated by percutaneous transluminal renal balloon angioplasty. Two months later, laparoscopic complete left adrenalectomy was performed. Hematoxylin-eosin staining and CYP11B2 immunostaining suggested that this tumor was an aldosterone-producing adenoma. After the two-stage treatment, her blood pressure decreased to a normal level without antihypertensive drugs. This case report raises our awareness of the simultaneous occurrence of RAS and PA. Under this condition, ARR could lead to a false-negative PA. Adrenal venous sampling is warranted to achieve a confirmed diagnosis. For subjects with complex etiologies of secondary hypertension, multi-stage treatment may be required.

Endovascular Versus Medical Management of Atherosclerotic Renovascular Disease: Update and Emerging Concepts.

Atherosclerotic renovascular disease is the most frequent cause of renovascular hypertension and its prevalence increases with age and in specific subset of patients, such as those with end-stage chronic kidney disease, heart failure, and coronary artery disease. Besides hypertension, atherosclerotic renovascular disease is responsible for several clinical manifestations, including life-threatening conditions, such as recurrent flash pulmonary edema, rapidly progressive chronic kidney disease, or acute kidney injury. Atherosclerotic renovascular disease is usually part of a more diffuse atherosclerotic process and requires a combination therapy including antihypertensive, antiplatelet and lipid-lowering agents, as well as optimization of antidiabetic treatment, if needed. Besides medical therapy, percutaneous renal angioplasty was supposed to be the most effective therapy for atherosclerotic renovascular disease, by leading to blood flow restoration. However, despite an apparently solid rationale, several randomized clinical trials failed to confirm the favorable effects of percutaneous renal angioplasty on blood pressure control, kidney function, cardiovascular and renal outcomes, previously reported in observational, retrospective and single-center cohorts, switching off the enthusiasm for this procedure. Several studies' limitations may partly account for this failure, including heterogeneity of diagnostic techniques, overestimation of the degree of renal artery stenosis, inappropriate timing of revascularization, multiple protocol revisions, frequent crossovers, and most importantly exclusion of patients at higher likelihood to respond to angioplasty. The purpose of this review is to summarize studies' potential weaknesses and provide guidance to the clinician for identification of patients who may benefit most from revascularization.

JS-AHA: AHA SESSION CLINICAL CASE; CLINICAL-PATHOLOGICAL CONFERENCE (CPC) IN COOPERATION WITH HYPERTENSION, AN AMERICAN HEART ASSOCIATION JOURNAL

A 35-year-old woman, with a known history of right renal artery FMD, presented at the Hypertension Outpatient Clinic for evaluation of resistant hypertension. The patient was an active smoker and had a single kidney after left nephrectomy for kidney malformation during childhood. The diagnosis of FMD had been made on the occasion of a previous pregnancy at 23 years, complicated by preeclampsia and an angioplasty had been performed. Work-up disclosed a recurrence of right renal artery stenosis, and a new renal angioplasty was performed. Blood pressure normalized after the procedure. At 36 years, the patient had another pregnancy, also complicated by preeclampsia and preterm delivery. An Echo-Doppler performed during pregnancy and an Angio-CT after delivery, allowed ruling out recurrence of renal artery stenosis. At 43 years, she was admitted to the emergency room for thoracic pain. The coronarography was in favour of a coronary spasm. There was no coronary stenosis or image suggestive of a Spontaneous Coronary Artery Dissection. At 54 years, the patient was again admitted in emergency for malignant hypertension associated with severe acute renal failure. She also reported a history of lower limbs claudication since several months. An abdominal CT disclosed dissection complicated by occlusion of the right renal artery, dissection of both iliac arteries as well as a severe stenosis of the infra-renal aorta. An angioplasty with insertion of stents in the right renal artery and the aorta was performed. After the procedure, a partial normalization of renal function was observed, and blood pressure control was achieved on 3 medications. During the recovery, the patient presented a skin rash associated with a general feeling of discomfort, with spontaneous resolution after a few days. One year later, following a control Angio-CT of the abdomen, an anaphylaxis episode occurred, requiring Adrenaline administration. Iodine contrast allergy was suspected, but milder hypersensitivity symptoms occurred in the following months, without exposition to a clear trigger. An allergology work-up was performed with final diagnosis of secondary Mast Cell Activation Syndrome. B-Blockers and ACE-inhibitors were contra-indicated and cautious premedication before further exposure to iodine contrast was recommended.

PS-BPR02-4: RENOVASCULAR HYPERTENSION FROM FIBROMUSCULAR DYSPLASIA WITHOUT ABNORMALITIES IN RENAL DOPPLER ULTRASOUND: A CASE REPORT.

Background: Renovascular hypertension (RVH) is one of the most common forms of secondary hypertension, and accounts for nearly 1% of all hypertension cases. It is characterized by compromised renal perfusion pressure, resultant renin secretion, and hypokalemia due to secondary hyperaldosteronism. Arteriosclerosis is a common underlying pathogenesis in middle-aged and older adults, whilst fibromuscular dysplasia is occasionally seen in younger patients with RVH. Since cardiovascular complications are of grave concern in RVH, early detection and appropriate therapeutic intervention are particularly important. Here, we report a case of renovascular hypertension from fibromuscular dysplasia which was incidentally unveiled during close examination of an adrenal tumor. Case report: A 55-year-old woman was being treated for hypertension by her primary care physician. She was referred to our hospital for a thorough examination of her right ureteral stone, which necessitated a CT scan incidentally revealing an left adrenal nodule measuring 8 mm in size. Primary aldosteronism was unlikely based on the lack of renin suppression (active renin concentration, 36.5 pg/mL; plasma aldosterone levels, 263 pg/mL and aldosterone-renin ratio < 40 under treatment with nifedipine 40 mg/day. Ultrasound of the kidney demonstrated a notable difference in size between the right and left kidneys of 87 mm and 106 mm, respectively, albeit Renal Artery Doppler failed to suggest the renal artery stenosis. CT scan with contrast material revealed the remarkable irregularity and “string on beads” sign on the distal main trunk of the right renal artery. Renovascular hypertension from fibromyalgia dysplasia was suspected, and percutaneous renal artery angioplasty was performed. After the pressure gradient across the stenotic lesion (105/99 mmHg on the distal side and 125/67 mmHg on the proximal side of the renal artery) was verified, balloon dilation was applied. The procedure was successful as the pressure gradient virtually resolved (105/95 mmHg on the distal side and 109/101 mmHg on the proximal side of the renal artery). Digital subtraction angiography indeed reaffirmed improvement in blood flow. Conclusion: Renovascular hypertension can go unnoticed solely based on renal Doppler Ultrasound. This was a case in which renovascular hypertension from fibromuscular dysplasia was incidentally identified in CT scan designated as a work-up for an adrenal tumor.

PS-C20-9: ANTIPLATELET AND ANTICOAGULANT THERAPY DURING ANGIOPLASTY PROCEDURES FOR ATHEROMATOUS OR FIBROMUSCULAR DYSPLASIA RENAL ARTERY STENOSIS IN ESH EC FRENCHS CENTRES

Introduction: Recommendations framing antiplatelet therapy (APT) and/or anticoagulation (AC) therapy during renal artery angioplasty procedures remain succinct or absent. However, the usefulness of this medical therapy is supported by pathophysiology and follow-up of these arterial damage (1). Objectives: The aim was to describe the practice of using APT and AC in the 17 French ESH-EC during renal artery angioplasties for atheromatous stenoses (AS) or fibromuscular dysplasia stenoses (FMD). Materials and Methods: Sending of a questionnaire via the French Society of Hypertension mailing to collect data with a reminder 1 month later. Results: Are summarized in the table. 12 centres responded partially or completely for AS and 10 for FMD. 2 centres considered that they did not recruit enough; 3 did not respond. Discussion/Conclusion: In AS, single APT before angioplasty is the rule, while double APT is routine after angioplasty for 1 month, followed by single APT over the long term. In FMD, in most cases (90% of cases) there is no double APT before or after angioplasty (except in the case of dissection), while a single APT is continued in 60% of cases over the long term. Anticoagulants are reserved for bolus injection in operating room (with some exceptions) for both AS and FMD. For AS, the handling of APT (duration, dose) differs, due to the lack of recommendations. In contrast, the use of AC/APT seems to be homogeneous in FMD before and during angioplasty, in accordance with the recommendations (1). New observational studies and randomized controlled trials must be part of a future international guideline. 1. Gornik HL et al. J Hypertens. 2019 Feb;37(2):229–252 Members of the French Society of Hypertension (Société Française d’Hypertension Artérielle - SFHTA): B Bouhanick, J Amar, L Amar, J Blacher, PY Courand, P Delsart, T Denolle, J Doublet, JP Fauvel, P Fesler, X Girerd, S Le Jeune, C Pelletier, P Rossignol, M Rodière, F Silhol, M Lopez-Sublet.

Renal Stem Cells, Renal Resistive Index, and Neutrophil Gelatinase Associated Lipocalin Changes After Revascularization in Patients With Renovascular Hypertension and Ischemic Nephropathy.

Percutaneous transluminal renal angioplasty (PTRA) with or without stenting is the gold standard therapy in patients with atherosclerotic renal artery stenosis (aRAS). However, therapeutic success depends on the correct timing of revascularization and the reversibility of the renal damage. We report a case series of patients treated with PTRA for renovascular hypertension and ischemic nephropathy. We measured bilateral renal resistive index (RRI), circulating renal stem cells (RSC), and Neutrophil Gelatinase Associated Lipocalin (NGAL) at baseline and after PTRA at different time points to understand their changes in post-revascularization. At baseline, the studied patients (n=5) had different RSC levels. After PTRAs, all patients showed an improvement in blood pressure, while renal function varied differently within the studied subjects. RRI >0.75 at baseline and the absence of NGAL decrease after PTRAs were associated with post-PTRA renal function worsening, despite an increase of RSC in all patients. Although limited to a few patients, our observation allowed the exploration of the behaviour of the studied parameters in different degrees of renal ischemia. This revealed different disease models suggesting the importance of further investigations in larger and homogeneous cohorts to confirm that a greater basal RSC percentage, low RRI values before PTRA, and a post-revascularization NGAL reduction could be related to better renal outcomes in aRAS patients.

PS-R04-2: A CASE OF SUCCESSFUL PERCUTANEOUS TRANSLUMINAL RENAL ANGIOPLASTY (PTRA) FOR RENAL ARTERY STENOSIS ASSOCIATED WITH TAKAYASU'S ARTERITIS

Introduction: In Japan, renal vascular hypertension based on renal artery stenosis (RAS) accounts for 1% of all hypertensive patients, and RAS is present in approximately 10% of autopsy cases of coronary artery disease and cerebrovascular disease. As ischemic nephropathy and complications of cardiovascular disease (CVD) due to RAS are common, early diagnosis and treatment for RAS is important. However, results of several large clinical trials have not shown the efficacy of percutaneous transluminal renal angioplasty (PTRA) for atherosclerotic RAS. Case: 51-year-old woman who diagnosed as Takayasu's arteritis (TA) 35 years ago, had been treated with 5 mg daily of prednisone. She presented with hypertension and edema in both legs a year before admission. Her examination at that time revealed increased serum creatinine from 1.0 to 1.7 mg/dL, high proteinuria (7.3 g/gCr), high renin activity (47.0 ng/mL/hr) and right RAS. Eight months before admission, she had an operation for ruptured descending aorta. She had recurrent episodes of dyspnea on exertion, worsening leg edema and severe hypertension and was admitted to the hospital for the treatment. Clinical course: In addition to severe hypertension (190/80 mmHg) and progression of RAS, she had pulmonary congestion, high brain natriuretic peptide (BNP) level (1149.5 pg/mL), increasing creatinine levels (Cr 3.1 mg/dL), and left non-functioning kidney on admission. Despite taking 8 types of antihypertensive drugs and diuretics without renin-angiotensin system inhibitors, blood pressure and fluid retention were poorly controlled, and thus we decided to perform PTRA for the right RAS. After the PTRA, edema, hypertension and pleural effusion had been dramatically improved. In addition, we could observe decrease of serum creatinine (Cr 1.6 mg/dL), proteinuria (0.5 g/gCr) and plasma renin activity (1.9 ng/mL/hr). Therefore, we reduced the antihypertensive drugs from 8 to 2. Discussions: Although the benefit of PTRA for RAS associated with TA remains unclear, the clinical course suggests that the success of PTRA in this case may be related to the fact that the RAS was complicated by TA. It also suggests that we should consider PTRA in cases of hypertension and pulmonary congestion associated with RAS which are difficult to control like this case. Conclusion: We have experienced a case of RAS associated with TA that was successfully treated with PTRA.

PS-R07-4: EFFICACY OF DOPPLER ULTRASOUND FOR INVESTIGATING THE CAUSE OF WORSENING RENAL FUNCTION AND HYPERTENSION IN A CASE OF RENOVASCULAR HYPERTENSION

A 72-year-old man visited our hospital after his blood pressure increased from 130/80 to 170/95 mmHg and systemic edema appeared over the past two months. His renal function also deteriorated, with serum creatinine increasing from 2.0 to 4.7 mg/dL. He had developed hypertension aged 40 years and cerebral infarction aged 66 years, and had smoked from 16 to 55 years old. Upon admission, plasma renin activity was 14.8 ng/mL/h, serum aldosterone was 169.4 pg/mL, and he was under treatment with telmisartan 40 mg/day, bisoprolol 5 mg/day, cilnidipine 20 mg/day, and nifedipine 20 mg/day. Computed tomography showed a calcified lesion at the root of the right renal artery and atrophy of the left kidney. There was no postrenal renal failure. On Doppler ultrasound, the right intrarenal artery had no systolic peak wave and the blood flow waveform rose slowly, suggesting renal artery stenosis. Therefore, we suspected that the cause of worsening renal function and hypertension was the deterioration of his one remaining functional (right) kidney, treatment with angiotensin II receptor blocker, and progression of right renal artery stenosis. As this case met the indication criteria for percutaneous transluminal renal angioplasty (PTRA) (resistant to treatment, exacerbated hypertension, and renal artery stenosis in one kidney), we performed angiography and PTRA despite end-stage renal failure. Angiography revealed > 90% stenosis at the root of the right renal artery, and the patient was diagnosed with renovascular hypertension. Following renal artery stenting, the renal stenosis disappeared, blood pressure decreased to 135/75 mmHg, renal function improved to serum creatinine level 2.2 mg/dL, and the edema disappeared. On renal Doppler ultrasound, the waveform of intrarenal blood flow in the right kidney showed a normal pattern. In this case of renovascular hypertension, renal Doppler ultrasound was useful for investigating the cause of worsening renal function and hypertension that occurred over a period of several months.

Percutaneous Transluminal Renal Angioplasty for Fibromuscular Dysplasia and Prognostic Risk Factors: A Retrospective Chinese Cohort Study

Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory vascular disease involving small-to-medium-sized arteries. The characteristics of Chinese patients with FMD remain unclear. We retrospectively analyzed the data of patients with renal FMD who underwent percutaneous transluminal renal angioplasty (PTRA) for the first time at Fuwai Hospital between 2010 and 2021. The variables were selected through least absolute shrinkage and selection operator regression (LASSO), and logistic regression models were constructed to identify independent risk factors. A total of 116 patients (52 males, median age at diagnosis, 25.0 years) were enrolled. Elevated blood pressure was the leading complaint. After a median follow-up period of 18.0 months (interquartile range: 6.0-48.0 months), hypertension recurred in 34 patients and restenosis in nine patients, among whom four patients underwent secondary intervention and one patient underwent surgical revascularization. Bilateral renal artery involvement (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.11-6.15; p = 0.028) and age at hypertension onset (OR: 0.93, 95% CI: 0.88-0.99; p = 0.018) were independent prognostic factors for adverse outcomes. The results indicate that patients with bilateral renal artery involvement and younger age at hypertension onset are more likely to have poorer clinical outcomes after PTRA, and should be more closely monitored.

745 INTERDISCIPLINARY EVALUATION IN RESISTANT ARTERIAL HYPERTENSION

Abstract Background Arterial hypertension is a complex and in most cases multifactorial pathology. Despite the numerous pharmacological treatments available, it is estimated that in Europe only 25%-39% of hypertensive patients achieve adequate blood pressure (BP) control. Renal arteries denervation (RDN) is an additional therapeutic weapon, complementary to Optimal Medical Therapy (OMT) in patients with resistant or refractory primary (or essential) arterial hypertension. In order to improve patients management and select those who are eligible for renal denervation, our Center has established the Interdisciplinary Group for the Treatment of Resistant Arterial Hypertension (G.I.T.I.A.R.), including Cardiologists, Nephrologists, Internists and Geriatricians. Methods From January 2018 to July 2022 the G.I.T.I.A.R. held twelve meetings evaluating 62 patients with resistant or refractory forms of arterial hypertension, contraindications or intolerance to antihypertensive drugs, suspected secondary or pseudoresistant forms (i.e. linked to poor patient compliance, drugs and/or inadequate dosages, concomitant intake of substances with hypertensive effect, incorrect measurements). For each of them, medical therapy was optimized and the need for second level diagnostic tests, multi-specialist follow-up and RDN candidacy were assessed. After three, six, twelve months and then annually following RDN, the patients underwent clinical and multi-specialist evaluation (where deemed appropriate), blood tests monitoring and 24-hour ambulatory blood pressure monitoring (ABPM). Results Of the 62 patients evaluated by the G.I.T.I.A.R., 64.5% (n=40) were male. The mean age at the time of evaluation was 64 years (range 18-87). After the first collegial discussion, 46.8% (n=29) have been declared eligible for RDN, while 53.2% (n=33) of the patients was initially rejected: 39.4% of these (n=13) for suspected or ascertained secondary hypertension, 12.1% (n=4) for the possibility of further optimization of medical therapy, 48.5% (n=16) for the presence of inclusion or exclusion criteria of ongoing studies design. Among the excluded patients, six presented moderate renal artery stenosis on non-invasive imaging: in two patients (33.3%) the stenosis turned out to be hemodynamically significant on angiographic and functional evaluation (Pd/Pa measurement), so renal angioplasty was performed; RDN was performed in the remaining 66.7% (n=4), in which a hemodynamic significance of the stenosis was excluded. Of the subgroup who had optimized medical therapy, one patient (25%) was subsequently referred to RDN for failure of all pharmacological strategies, while 3 of 4 (75%) achieved adequate BP control. Conclusions Resistant arterial hypertension is associated with an increased risk of development and progression of cardiovascular and renal diseases, with a significant impact on mortality and morbidity. Renal denervation has proved to be an effective and safe therapeutic strategy, complementary to OMT, whose selection of the ideal patient actually represents one of the greatest challenges. The integrated multidisciplinary approach improves the management of the hypertensive patient, the individualization of therapy and allows the identification of subjects who may benefit from RDN.

169: SITOSTEROLEMIA PRESENTING WITH SEVERE HYPERTENSION AND CONGESTIVE HEART FAILURE IN A CHILD

Introduction: Sitosterolemia is an autosomal recessive condition caused by pathogenic variants in the ABCG5/ABCG8 genes that prohibit the body from excreting plant sterols, causing build-up in the soft tissues and systemic vasculature. Pediatric vasculopathy secondary to sitosterolemia is poorly described, and there is no clear guidance on the management of complications, including cardiac dysfunction. This case report describes the diagnosis and acute management of a child with severe systemic hypertension, multiple levels of arterial stenosis, and cardiomyopathy presenting in congestive heart failure and ultimately diagnosed with sitosterolemia. Description: An 8-year-old Amish male with no past medical history presented to the emergency department with emesis and associated fatigue and abdominal pain. Vital signs were significant for severe systemic hypertension (BP 220/110), a gallop rhythm, hepatomegaly, cardiomegaly, and mid-aortic narrowing on CT angiogram. Exam was also notable for bilateral knee xanthomas. Laboratory data after admission to the pediatric cardiac ICU showed elevated BNP (peak 4418 pg/mL) and total cholesterol (317 mg/dL) levels. Echocardiogram showed severe mitral and tricuspid valve regurgitation, severely dilated and concentrically hypertrophied and dysfunctional left ventricle, ejection fraction of 30%, and pulmonary hypertension. Consultations included genetics, cardiology, nephrology, and vascular surgery. Initial management included a continuous Milrinone infusion and loop diuretics with improved BP and congestive heart failure symptoms. Cardiac catheterization including coronary and renal angiograms demonstrated severe proximal right coronary artery stenosis and bilateral renal artery stenosis. Right coronary artery and left renal artery angioplasties were performed with good results, and showed significant improvement in parameters of ventricular function and pulmonary arterial hypertension. Genetic testing and positive serum plant sterols confirmed the diagnosis of sitosterolemia. Discussion: Sitosterolemia is a rare genetic disorder and a rare cause of pediatric arteriopathy. Early recognition can prevent the development of life-threatening systemic hypertension, arterial stenosis including coronary artery disease, and cardiomyopathy.

Ultra-Low-Dose Contrast Using Transluminal Renal Angioplasty: The ULTRA Study.

Although severe atherosclerotic renal artery stenosis (ARAS) is a predictor of future cardiovascular events, large trials have not shown the benefits of percutaneous transluminal renal angioplasty (PTRA). This study aimed to validate the safety and efficacy of PTRA using low-concentration digital subtraction angiography (LC-DSA) in patients with severe ARAS and advanced chronic kidney disease (CKD). This prospective study was conducted between August 2018 and October 2021. Eighteen patients with 20 lesions, CKD stage 3b or worse, and significant renal artery stenosis were included and underwent PTRA using ultra-low-dose contrast medium. The primary endpoint was a change in renal function based on serum creatinine (sCr) level. The mean sCr level significantly improved from 3.34 ± 1.8mg/dL pre-PTRA to 2.48 ± 1.19mg/dL at 1 month post-PTRA (P = .02). The mean amount of contrast used was 8.3 ± 3.9mL per vessel. More severe stenosis and rapid deterioration of renal function before treatment were associated with improved kidney function. No cardiovascular or renal complications such as stroke or contrast-induced nephropathy were observed during the 30-day period. PTRA using an ultra-low-dose contrast medium is safe and provides acceptable results.

Aligning Orifice of the Renal Artery with Fish-Mouth FIXation Technique During Endovascular Aortic Aneurysm Repair for Hostile Neck Anatomy.

Background: As the success of endovascular aortic aneurysm repair (EVAR) depends on sufficient proximal fixation of the endograft to the aortic wall, the proximal hostile neck anatomy (HNA) is the major potential treatment-limiting factor in EVAR. The Aorfix endovascular stent graft was designed to operate on highly angulated aortic necks. The Aligning Orifice of the Renal artery with fish-mouth FIXation (AORFIX) technique uniquely and accurately aligns the trough part of the proximal stent end with the orifice of the lower renal artery and is used to optimize the proximal fish-mouth design for maximum proximal seal use. Herein, we aimed to evaluate the usefulness of the AORFIX technique for EVAR in patients with HNA. Methods: Eighty-one consecutive patients who underwent EVAR with the AORFIX technique (+AORFIX technique group, n = 16) and without (standard group, n = 65) were evaluated. The HNA was defined as any of the following: neck angulation ≥60°, neck length ≤15mm, or neck thrombus or calcification ≥50% of the circumference and conical neck. Results: Each HNA criterion was similar between the two groups. However, the average number of HNA criteria was significantly higher in the +AORFIX technique group (1.9 ± .2 vs. 1.3 ± .1; P < .01). The two groups showed 100% procedural success. The concurrent renal angioplasty and stenting rates (88% vs. 4.6%; P < .01) were significantly higher in the +AORFIX technique group. There were no 30-day deaths in either group and no in-hospital device-related events in the +AORFIX technique group. The median follow-up period was 39months, and there was no significant between-group difference in freedom from reintervention rate (+AORFIX group vs. standard group, 100% vs. 91.0%; P = .327). Conclusion: EVAR using the AORFIX technique might be useful even in patients with more complex HNA.