Therapy For Renal Artery Stenosis Research Articles

Cardiovascular Disease Prevention in Patients With Atherosclerotic Renovascular Disease-Induced Resistant Hypertension: Further Considerations for 24-Hour BloodPressure Profiles.

Cardiovascular Disease Prevention in Patients With Atherosclerotic Renovascular Disease-Induced Resistant Hypertension: Further Considerations for 24-Hour BloodPressure Profiles.

Cardiac structure and function after revascularization versus medical therapy for renal artery stenosis: the ASTRAL heart echocardiographic sub-study

BackgroundThe ASTRAL trial showed no difference in clinical outcomes between medical therapy and revascularization for atherosclerotic renal vascular disease (ARVD). Here we report a sub-study using echocardiography to assess differences in cardiac structure and function at 12 months.MethodsASTRAL patients from 7 participating centres underwent echocardiography at baseline and 12 months after randomisation. Changes in left ventricular ejection fraction (LVEF), left ventricular mass (LVM), left atrial diameter (LAD), aortic root diameter (AoRD), E:A, and E deceleration time (EDT) were compared between study arms. Analyses were performed using t-tests and multivariate linear regression.ResultsNinety two patients were included (50 medical versus 42 revascularization). There was no difference between arms in any baseline echocardiographic parameter. Comparisons of longitudinal changes in echocardiographic measurements were: δLVEF medical 0.8 ± 8.7% versus revascularization − 2.8 ± 6.8% (p = 0.05), δLVM − 2.9 ± 33 versus − 1.7 ± 39 g (p = 0.9), δLAD 0.1 ± 0.4 versus 0.01 ± 0.5 cm (p = 0.3), δAoRD 0.002 ± 0.3 versus 0.06 ± 0.3 cm (p = 0.4), δE:A − 0.0005 ± 0.6 versus 0.03 ± 0.7 (p = 0.8), δEDT − 1.1 ± 55.5 versus − 9.0 ± 70.2 ms (p = 0.6). In multivariate models, there were no differences between treatment groups for any parameter at 12 months. Likewise, change in blood pressure did not differ between arms (mean δsystolic blood pressure medical 0 mmHg [range − 56 to + 54], revascularization − 3 mmHg [− 61 to + 59], p = 0.60).ConclusionsThis sub-study did not show any significant differences in cardiac structure and function accompanying renal revascularization in ASTRAL. Limitations include the small sample size, the relative insensitivity of echocardiography, and the fact that a large proportion of ASTRAL patient population had only modest renal artery stenosis as described in the main study.

Endovascular Treatment of Renal Artery Stenosis in the Post CORAL Era.

Atherosclerotic renal artery stenosis (RAS) is highly associated with hypertension and renal insufficiency. Determining causation and who may benefit from RAS treatment remains difficult. The role of endovascular management of atherosclerotic RAS was challenged by several recent randomized controlled trials (RCT) which failed to demonstrate benefit of stenting. In the largest RCT to date, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) study did not find benefit of revascularization compared to medical therapy alone. While such RCTs represent the highest level of evidence to date, the conclusions drawn from them should be interpreted with caution due to substantial flaws in study design, inclusion, and exclusion criteria. The current AHA/ACC recommendations for RAS management are supported by many level-II evidence cohort studies which consistently found benefit of revascularization in groups with the highest likelihood of clinically significant RAS. Further study of these patient groups are needed to define a clear role for endovascular therapy of renal artery stenosis.

Revascularisation of renal artery stenosis as a therapy for heart failure: an observational cohort study

BackgroundHeart failure contributes to 5% of all hospital admissions, and mortality is more than 50% at 4 years. 54% of patients with a left ventricular ejection fraction of less than 40% have renal artery stenosis. The potential benefit of revascularisation for heart failure is not established. We aimed to compare clinical outcomes for renal artery revascularisation with medical therapy for renal artery stenosis associated with heart failure as the first step towards validating revascularisation as a therapeutic option in heart failure. MethodsIn a prospective, longitudinal observational study at a single UK nephrology centre, we recruited patients with atherosclerotic renal artery stenosis (>50% as judged by CT, MR, or direct angiography). Endpoints were all-cause mortality and hospital admission for heart failure. Survival analyses were performed with Cox proportional hazard model adjusted for age, estimated glomerular filtration rate (eGFR), and cardiovascular comorbidities. Ethics approval was granted by South Manchester Research Ethics Committe. Findings611 patients (152 [25%] with and 459 [75%] without heart failure) were recruited. Mean age was 70 years (SD 9), 348 (57%) were men, 183 (30%) had diabetes, and mean eGFR was 33 mL/min per 1·73 m2 (SD 19). Patients with and without heart failure were similar with to sex, diabetes, and eGFR. 367 participants (60%) died over a follow-up of a mean of 4·3 years (SD 3·6). 87 patients without heart failure (19%) underwent revascularisation compared with 47 with heart failure (31%). The adjusted hazard ratio (HR) for death in heart failure compared with no heart failure was 1·9 (95% CI 1·5–2·5, p<0·0001). For patients without heart failure, the adjusted HR for death in revascularisation compared with receiving medical therapy was 0·8 (0·5–1·1, p=0·16). For heart failure, the HR was 0·6 (0·3–0·9, p=0·01). The HR for hospital admission for heart failure in revascularised patients was 0·2 (0·0–1·1, p=0·06). InterpretationRevascularisation of renal artery stenosis in heart failure is associated with a substantial reduction in all-cause mortality and hospital admission, although such observational data might be complicated by hidden confounders. These findings are encouraging for the development of a randomised trial of renal artery revascularisation versus medical therapy in heart failure, and suggest that investigation for renal artery stenosis should be considered more frequently in heart failure clinics. FundingNone.

Medical therapy for renal artery stenosis

The management of renal artery stenosis remains controversial with randomized trials suggesting that revascularization is no better than medical therapy. Thus all patients with atheromatous renovascular disease should be treated with medical therapy. However optimal therapy has not been clearly defined by atheromatous renovascular disease trials; despite this, there are data to support the use of several pharmacologic agents among this group of patients. Such a regimen should include an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker, a β-blocker, a statin and aspirin. Additional therapies will often be required and need to be individualized to a given patient based upon comorbid conditions.

Resolution of Renal Failure 1 Month After Onset through Angioplasty of Renal Artery Stenosis

The stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function (STAR) and revascularization versus medical therapy for renal-artery stenosis (ASTRAL) trials concluded that renal artery angioplasty was not superior to medical management in delaying progression to renal failure or controlling blood pressure in a selected population. There were several criticisms of the STAR trial’s methodology, and an important criticism of ASTRAL was that the patient was excluded if their clinician was uncertain of the value in correcting the stenosis. Anuric renal failure by renal artery stenosis is a rare occurrence and falls outside this criteria.

Revascularization Versus Medical Therapy for Renal Artery Stenosis: Antihypertensive Drugs and Renal Outcome

Endovascular procedures may play a role in renal artery stenosis (RAS) treatment in attempt to preserve renal function and improve hypertension control. We determined renal outcome and the incidence of restenosis in patients with RAS treated with renal percutaneous transluminal angioplasty and stenting (RPTAs) and medical therapy versus patients with RAS treated only with medical therapy. We performed an observational study based on 93 patients with RAS. In all, 53 patients underwent RPTAs in association with medical therapy and 40 patients were only treated pharmacologically. In patients receiving RPTAs, a better renal outcome, a decrease of restenosis rate, and systolic-diastolic blood pressure were associated with angiotensin receptor blockers (ARBs) + angiotensin-converting enzyme inhibitors (ACE-is) therapy. In patients treated with medical therapy alone, renal improvement was related to ARBs in association with BBs (β-blockers; P < .0001). This study suggests that medical therapy may exert beneficial effects in patients with RAS.

Revascularization versus Medical Therapy for Renal-Artery Stenosis

Revascularization versus Medical Therapy for Renal-Artery Stenosis

Revascularization versus Medical Therapy for Renal-Artery Stenosis

Revascularization versus Medical Therapy for Renal-Artery Stenosis

Revascularization versus Medical Therapy for Renal-Artery Stenosis

Revascularization versus Medical Therapy for Renal-Artery Stenosis

Revascularization versus Medical Therapy for Renal-Artery Stenosis

Revascularization versus Medical Therapy for Renal-Artery Stenosis

Revascularization versus Medical Therapy for Renal-Artery Stenosis

Revascularization versus Medical Therapy for Renal-Artery Stenosis

Vaskuläre Rekanalisationstechniken: Nierenarterienstenosen

Decisive for the evaluation for radiological interventional therapy of renal artery stenosis, are the morphologic diagnostic by Duplex sonography, non-invasive cross-sectional angiography and digital subtraction angiography in addition to the anamnesis and clinical constellation. A standardized diagnostic algorithm and an evidence-based indication status contribute just as importantly to improvement of outcome as the implementation of uniform peri-interventional measures and a structured procedure for angiography, percutaneous transluminal renoangioplasty and follow-up. The aim of this article is to provide a practical introduction for the current radiological management of renal artery stenosis.

Endovascular Therapy of Renal Artery Stenosis: Where Do We Stand Today?

Angioplasty and stent therapy for stenoses of the renal artery have long been part of the everyday life of interventional radiologists. Newer studies, however, challenge the clinical significance of the method. A decisive advantage of endovascular techniques for the treatment of arterial hypertension as opposed to therapy with modern antihypertensives could not be proven in individual randomized studies, even though blood pressure control was observed to be facilitated by PTA (percutaneous transluminal angioplasty). Renal function often did not show any sustainable improvement following elimination of the renal artery stenosis. However, progression of kidney insufficiency could be slowed down. There is still no general justification from the existing data for the treatment of incidental stenoses. Many questions remain open regarding the technique. Whereas fibromuscular dysplasia can be treated by balloon angioplasty as a general rule, a metallic endoprosthesis must often be used for atherosclerotic stenoses. The outstanding morphologic results of stent therapy in the short and medium term course are often simply used to justify primary stent implantation in ostial stenoses.

Percutaneous Endovascular Therapy of Renal Artery Stenosis:Technical and Clinical Developments in the Past Decade

Renal artery stenosis may initiate or exacerbate arterial hypertension and/or renal insufficiency. During the last decade, technical improvements of diagnostic and interventional endovascular tools have led to more widespread use of endoluminal renal artery revascularization and broader indications for this type of therapy. Since the first renal artery angioplasties performed by Felix Mahler and Andreas Gruntzig in 1978, numerous single-center studies have documented the benefits of percutaneous renal revascularization. In the early 1990s, stent implantation was added to the interventionist's armamentarium for treating renal artery stenosis due to atherosclerosis or fibromuscular dysplasia. The meta-analysis of 3 randomized studies comparing balloon angioplasty with best medical therapy found intervention to be beneficial for blood pressure control but not for preservation of renal function. Despite the absence of randomized studies, there is mounting evidence that stenting of hemodynamically relevant atherosclerotic renal artery stenosis has a positive impact on blood pressure control and renal function. This article summarizes the technical improvements in these endovascular tools during the last decade and gives an overview concerning their clinical impact on renal artery revascularization.

Percutaneous Endovascular Therapy of Renal Artery Stenosis: Technical and Clinical Developments in the past Decade

Few procedures in the history of medicine have been more controversial than carotid artery stenting (CAS) for the management of carotid artery occlusive disease. Introduced just as the randomized trials were establishing carotid endarterectomy as the gold standard for carotid interventions, CAS has finally reached the point in its development when dedicated stenting systems are being tested in randomized clinical trials. Assisted by the concomitant use of distal protection devices, CAS has shown equipoise with endarterectomy in terms of safety at 30 days. This review summarizes the completed and ongoing CAS trials and the applications of endovascular techniques in the supra-aortic vessels.

Compound angulation for the angiographic evaluation of renal artery stenosis.

The increasing role of percutaneous transluminal angioplasty in the therapy of renal artery stenosis has, in turn, emphasized the need to optimize imaging of the entire length of the main renal artery and its major branches. The usual angiographic positioning techniques for anteroposterior and oblique views may not be adequate to define the precise location and extent of a stenosis. The authors combine oblique projections with sagittal angulation of the x-ray tube to augment the standard imaging methods for selective renal arteriography.