Treatment Of Atherosclerotic Renal Artery Stenosis Research Articles

Prise en charge de la sténose athéromateuse d’artère rénale en 2016

Endovascular revascularization as treatment of atherosclerotic renal-artery stenosis (aRAS) is controversial since 3 large and multicentric randomised trials (CORAL, ASTRAL, STAR) failed to prove the superiority of percutaneous transluminal renal-artery stenting (PTRAS) over medical treatment only (MT). However, considering the multiple bias of these trials, among which questionable inclusion criterias, these results must be extrapolated in clinical practice with caution. New pathophysiological data have been helping to understand why restoring blood flow does not necessarily lead to kidney function improvement. Today, the diagnostic approach must in one hand confirm the artery stenosis and on the other hand assess its severity and impact on the kidney. Therapeutic options still lie on the American guidelines published in 2006, since no study data can be reasonably used in everyday practice. However, particular sub-groups of patients who could benefit from revascularisation have been identified through recent cohort studies. Further prospective studies are needed in order to confirm the superiority of PTRAS in these populations. Meanwhile, multidisciplinary approach should be promoted, in order to provide the best treatment for each patient.

Marked improvement of renal failure and severe hypertension after renal artery stenting in the solitary functioning kidney

Atherosclerotic renal artery stenosis (ARAS) can cause resistant hypertension, progressive renal failure and/or cardiorenal syndrome. Although no randomized study to demonstrate the superiority of renal stenting over medical treatment is available, a case-sensitive approach is required for the treatment of ARAS. Here, we describe a case report of a symptomatic ARAS patient with a solitary functioning kidney in which successful detection of ARAS by ultrasonography examination with the Doppler method and timely renal artery stenting were performed.<Learning objective: The clinical efficacy of renal artery stenting for symptomatic ARAS as a method of lowering blood pressure and preventing deterioration in renal function remains unproven. However, renal artery stenting performed based on enough investigation of clinical course and information by ultrasonography examination with Doppler method results in benefit to the patient with ARAS.>

Revascularization in Renal Artery Stenosis

The predominant cause of renal artery stenosis (RAS) is atherosclerosis. Clinical manifestations of atherosclerotic RAS are both direct (hypertension and kidney dysfunction) and indirect (increased cardiovascular events and mortality). However, in many cases, atherosclerotic RAS seems to be an incidental finding with no discernable effects. Antihypertensive medications such as renin-angiotensin-aldosterone system inhibitors, along with statins and aspirin, have significantly improved the medical treatment of atherosclerotic RAS. However, revascularization is still advocated in a variety of clinical settings such as the preservation of renal function, recurrent episodes of "flash" pulmonary edema, and in patients with refractory hypertension. Current management guidelines indicate "resistant hypertension" as an indication for renal artery revascularization. A large number of observational studies support revascularization for both control of high blood pressure and/or preservation of renal function. Unfortunately, the favorable effects of revascularization on these end points seen in the observational studies were not reproduced in randomized controlled trials compared to medical therapy alone. The ability for revascularization to improve control of congestive heart failure or to prevent hard cardiovascular end points (eg, myocardial infarction or stroke) has not been tested in the randomized clinical trials published to date. Hence, the efficacy of intervention remains controversial, which poses a dilemma, especially given the large number of elderly patients with resistant systolic hypertension.

Atherosclerotic Renal Artery Stenosis Mimicking Fibromuscular Dysplasia

We experienced a case with atherosclerotic renal artery (RA) stenosis mimicking fibromuscular dysplasia (FMD). In this case, renal angiography, which is considered the ‘gold standard’ for diagnosing FMD, demonstrated a typical ‘string-of-beads’ sign. However, integrated backscatter intravascular ultrasound (IB-IVUS) showed severe atherosclerotic stenosis of the RA with a large amount of lipid pool. Therefore, we decided to perform adjunctive stent implantation which is considered optimal treatment of atherosclerotic RA stenosis.

Atherosclerotic Renal Artery Stenosis Mimicking Fibromuscular Dysplasia

We experienced a case with atherosclerotic renal artery (RA) stenosis mimicking fibromuscular dysplasia (FMD). In this case, renal angiography, which is considered the ‘gold standard’ for diagnosing FMD, demonstrated a typical ‘string-of-beads’ sign. However, integrated backscatter intravascular ultrasound (IB-IVUS) showed severe atherosclerotic stenosis of the RA with a large amount of lipid pool. Therefore, we decided to perform adjunctive stent implantation which is considered optimal treatment of atherosclerotic RA stenosis. Our case suggests that IVUS evaluation might be useful for an accurate diagnosis and to help develop a treatment strategy for revascularisation.

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.

Follow-up of combined intervention for patients with both renal and cerebral artery stenosis

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