cardiovascular-agents and Renal-Artery-Obstruction

Diabetes mellitus (DM) is also a cause of cardiovascular (CV) disease (CVD). Addressing the atherosclerotic CVD (ASCVD) burden in DM should reduce premature death and improve quality of life. Diabetes mellitus-associated ASCVD can lead to complications in all vascular beds (carotids as well as coronary, lower extremity, and renal arteries). This narrative review considers the diagnosis and pharmacological treatment of noncardiac atherosclerotic vascular disease (mainly in patients with DM). Based on current knowledge and the fact that modern DM treatment guidelines are based on CV outcome trials, it should be noted that patients with noncardiac CVD may not have the same benefits from certain drugs compared with patients who predominantly have cardiac complications. This leads to the conclusion that in the future, consideration should be given to conducting well-designed trials that will answer which pharmacological treatment modalities will be of greatest benefit to patients with noncardiac ASCVD.

Topics: Animals; Aortic Aneurysm; Cardiovascular Agents; Diabetes Mellitus; Humans; Hypoglycemic Agents; Peripheral Arterial Disease; Renal Artery Obstruction; Risk Assessment; Risk Factors; Stroke; Treatment Outcome

The aim of the study was to compare the efficacy of revascularization versus medical therapy in patients with atherosclerotic renal artery stenosis (ARAS). ARAS is the most common cause of secondary hypertension and is associated with several complications, such as renal failure, coronary artery disease, cardiac destabilization, and stroke. Medical therapy is the cornerstone for management of ARAS; however, numerous trials have compared medical therapy with revascularization in the form of percutaneous renal artery angioplasty (PTRA) or percutaneous renal artery angioplasty with stent placement (PTRAS). Medline (PubMed and Ovid SP), Embase, Cochrane Central Register of Controlled Clinical Trials (CENTRAL), and Cochrane Database of Systematic Review (CDSR) were searched till present (November 2013) to identify clinical trials where medical therapy was compared with revascularization (PTRA or PTRAS). We performed a meta-analysis using a random effects model. The heterogeneity was assessed using I2 values. The initial database search identified 540 studies and 7 randomized controlled trials, and 2,139 patients were included in the final analysis. Angioplasty with or without stenting was not superior to medical therapy with respect to any outcome. The incidence of nonfatal myocardial infarction was 6.74% in both the stenting and medical therapy group (odds ratio=0.998, 95% confidence interval 0.698 to 1.427, p=0.992), and incidence of renal events in stenting population was found to be 19.58% versus 20.53% in medical therapy (odds ratio=0.945, 95% confidence interval 0.755 to 1.182, p=0.620). In conclusion, PTRA or PTRAS does not improve outcomes compared with medical therapy in patients with ARAS. Future studies should investigate to identify patient subgroups that may benefit from such an intervention.

Topics: Animals; Atherosclerosis; Cardiovascular Agents; Global Health; Humans; Morbidity; Renal Artery Obstruction; Treatment Outcome; Vascular Surgical Procedures

Endovascular treatment for atherosclerotic renal artery stenosis (ARAS) was first performed >30 years ago and its use has increased rapidly since then. However, only recently have large randomized trials rigorously evaluated its clinical benefit.. We systematically reviewed the controlled studies on primary stenting for atherosclerotic renal artery stenosis. Studies were included if they compared the outcome of stenting with other treatments, or the outcome associated with different stent characteristics or stenting methods.. Stenting is preferred over angioplasty alone and over surgery when revascularization is indicated for ostial ARAS, except in cases of coexistent aortic disease indicating surgery. Randomized controlled trials showed no significant benefit and substantial risk of renal artery stenting over medication alone in patients with atherosclerotic ARAS without a compelling indication. Improvements in the procedure, such as with distal embolic protection devices and coated stents, are not associated with better clinical outcomes after stent placement for ARAS.. Recent evidence shows that impaired renal function associated with ARAS is more stable over time than previously observed. Optimal medical treatment should be the preferred option for most patients with ARAS. Only low-level evidence supports compelling indications for revascularization in ARAS, including rapidly progressive hypertension or renal failure and flash pulmonary edema.

Topics: Angioplasty; Atherosclerosis; Cardiovascular Agents; Evidence-Based Medicine; Humans; Patient Selection; Renal Artery Obstruction; Risk Assessment; Severity of Illness Index; Stents; Treatment Outcome; Vascular Surgical Procedures

Prospective randomized clinical trials that support operative correction of atherosclerotic renovascular disease or catheter-based intervention compared with optimal medical management are lacking. Despite various limitations in study design, each of the five randomized trials reported to date had demonstrated no apparent benefit for renal artery intervention compared with medical management. Three ongoing randomized trials promise to provide additional data and the results of these latter studies will likely dictate future reimbursement through the Centers for Medicare and Medicaid Services.

Topics: Angioplasty; Atherosclerosis; Cardiovascular Agents; Evidence-Based Medicine; Humans; Prospective Studies; Randomized Controlled Trials as Topic; Renal Artery Obstruction; Research Design; Treatment Outcome; Vascular Surgical Procedures

The management of atherosclerotic renal artery stenosis is controversial. Although it may appear intuitive that restoring normal blood flow to the kidney(s) is the treatment of choice, there are no data showing an obvious advantage of interventional therapy compared with medical therapy. In this article, we discuss the most recent advances in the treatment of atherosclerotic renal artery stenosis with a focus on randomized studies comparing medical treatment with angioplasty/stenting, particularly in patients with underlying renal dysfunction. The available data are still of limited quality but provide support against indiscriminate use of interventions, as these treatments appear no better than best medical treatment that focuses on blood pressure control, use of blockers of the renin-angiotensin system, and aggressive cardiovascular risk management.

Topics: Angioplasty, Balloon; Angiotensin Receptor Antagonists; Atherosclerosis; Cardiovascular Agents; Humans; Renal Artery Obstruction; Renal Insufficiency; Stents

A renal artery stenosis (RAS) is common among patients with atherosclerosis, up to a third of patients undergoing cardiac catheterization. Fibromuscular dysplasia is the next cause of RAS, commonly found in young women. Atherosclerosis RAS generally progresses overtime and is often associated with loss of renal mass and worsening renal function (RF). Percutaneous renal artery stent placement is the preferred method of revascularization for hemodynamically significant RAS according to ACC and AHA guidelines. Several randomized trials have shown the superiority of endovascular procedures to medical therapy alone. However, two studies ASTRAL and STAR studies were recently published and did not find any difference between renal stenting and medical therapy. But these studies have a lot of limitations and flaws as we will discuss (poor indications, poor results, numerous complications, failures, poor technique, inexperienced operators, ecc.). Despite these questionable studies, renal stenting keeps indications in patients with: uncontrolled hypertension; ischemic nephropathy; cardiac disturbance syndrome (e.g. "flash" pulmonary edema, uncontrolled heart failure or uncontrolled angina pectoris); solitary kidney. To improve the clinical response rates, a better selection of the patients and lesions is mandatory with: good non-invasive or invasive imaging; physiologic lesion assessment using transluminal pressure gradients; measurements of biomarkers (e.g., BNP); fractional flow reserve study. A problem remains after renal angioplasty stenting, the deterioration of the RF in 20-30% of the patients. Atheroembolism seems to play an important role and is probably the main cause of this R.F deterioration. The use of protection devices alone or in combination with IIb IIa inhibitors has been proposed and seems promising as shown in different recent reports. Renal angioplasty and stenting is still indicated but we need: a better patient and lesion selection; improvements in techniques and maybe the use of protection devices to reduce the risk of RF deterioration after renal stenting.

Topics: Angioplasty; Cardiovascular Agents; Clinical Trials as Topic; Evidence-Based Medicine; Humans; Patient Selection; Renal Artery Obstruction; Research Design; Risk Assessment; Risk Factors; Stents; Treatment Outcome

Atherosclerotic renovascular disease is an increasingly recognized cause of severe hypertension and declining kidney function. Patients with atherosclerotic renovascular disease have been demonstrated to have an increased risk of adverse cardiovascular events. Over the course of the last two decades renal artery revascularization for treatment of atherosclerotic renal artery stenosis (RAS) has gained great increase via percutaneous techniques. However the efficacy of contemporary revascularization therapies in the treatment of renal artery stenosis is unproven and controversial. The indication for renal artery stenting is widely questioned due to a not yet proven benefit of renal revascularization compared to best medical therapy. Many authors question the efficacy of percutaneous renal revascularization on clinical outcome parameters, such as preservation of renal function and blood pressure control. None of the so far published randomized controlled trials could prove a beneficial outcome of RAS revascularization compared with medical management. Currently accepted indications for revascularization are significant RAS with progressive or acute deterioration of renal function and/or severe uncontrollable hypertension, renal function decline with the use of agents blocking the renin-angiotensin system and recurrent flash pulmonary edema. The key point for success is the correct selection of the patient. This article summarizes the background and the limitations of the so far published and still ongoing controlled trials.

Topics: Angioplasty; Blood Pressure; Cardiovascular Agents; Evidence-Based Medicine; Humans; Hypertension, Renovascular; Randomized Controlled Trials as Topic; Renal Artery Obstruction; Risk Assessment; Risk Factors; Stents; Treatment Outcome

Atherosclerotic renovascular disease (aRVD) is an increasingly recognized cause of severe hypertension and declining kidney function. Patients with aRVD have been demonstrated to have an increased risk of adverse cardiovascular events compared with patients without aRVD. For these reasons, >45,000 renal artery revascularization procedures are performed annually, with significant growth observed in the number of procedures performed each year. The efficacy of contemporary revascularization therapies in the treatment of aRVD is unproven and controversial, with no level I data to support current practices. Lower-level data suggest that kidney function improvement is a key indicator of subsequent improved survival free of adverse cardiovascular events and dialysis, and that observed improvements of hypertension confer, at best, limited benefit. This review focuses on existing data on the management of aRVD, including data from completed and ongoing randomized clinical trials. This review also examines other existing data regarding aRVD that may guide current treatment and future research efforts into this significant clinical and public health problem until widely accepted level I evidence emerges.

Topics: Angioplasty; Atherosclerosis; Cardiovascular Agents; Disease Progression; Evidence-Based Medicine; Humans; Hypertension, Renovascular; Kidney; Patient Selection; Randomized Controlled Trials as Topic; Renal Artery Obstruction; Renal Dialysis; Stents; Treatment Outcome; Vascular Surgical Procedures

Renal artery stenosis (RAS) is usually caused by atherosclerosis or fibromuscular dysplasia. RAS leads to activation of the renin-angiotensin-aldosterone system and may result in hypertension, ischemic nephropathy, left ventricular hypertrophy and congestive heart failure. Management options include medical therapy and revascularization procedures. Recent studies have shown angiotensin receptor blockers (ARB) and angiotensin converting enzyme inhibitors (ACE-I) to be highly effective in treating the hypertension associated with RAS and in reducing cardiovascular events; however, they do not correct the underlying RAS and loss of renal mass may continue. Renal artery angioplasty was first performed by Gruntzig in 1978. The routine use of stents has increased technical success rates compared with angioplasty, and surgery is now only rarely performed. Although numerous case series claimed benefit in terms of blood pressure control, no adequately powered randomized, controlled, prospective study of renal artery interventions has reported their effect on cardiovascular morbidity or mortality. The CORAL trial, an ongoing study of renal artery stent placement and optimal medical therapy (OMT) funded by the National Institutes of Health, is the first study to attempt to do so. Until the CORAL trial results are in, physicians will continue to be faced with difficult choices when determining the optimal management for RAS patients and deciding which, if any, patients should be offered revascularization.

Topics: Angioplasty, Balloon; Atherosclerosis; Blood Pressure; Cardiovascular Agents; Cardiovascular Diseases; Clinical Trials as Topic; Evidence-Based Medicine; Humans; Hypertension, Renal; Kidney Function Tests; Patient Selection; Radiography; Renal Artery Obstruction; Risk Assessment; Risk Factors; Stents; Treatment Outcome

Patients with atherosclerotic renal artery stenosis may develop hypertension, recurrent pulmonary edema and chronic renal failure, but have a much higher risk of dying from stroke or myocardial infarction than of progressing to end-stage renal disease. Indeed, atherosclerotic renal artery stenosis typically occurs in high risk patients with coexistent vascular disease elsewhere. Recent controlled trials comparing medication to revascularization have shown that only a minority of such patients can expect hypertension cure, whereas the results of trials designed to document the ability of revascularization to prevent progressive renal failure are not yet available. Revascularization should be undertaken in patients with atherosclerotic renal artery stenosis and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition, especially if their renal resistance--index before revascularization is less than 80. With or without revascularization, medical therapy using antihypertensive agents, statins and aspirin is necessary in almost all cases.

Topics: Angiotensin-Converting Enzyme Inhibitors; Arteriosclerosis; Aspirin; Cardiovascular Agents; Combined Modality Therapy; Creatinine; Diagnostic Imaging; Drug Therapy, Combination; Heart Failure; Humans; Hypertension, Renovascular; Hypolipidemic Agents; Myocardial Infarction; Platelet Aggregation Inhibitors; Pulmonary Edema; Radionuclide Imaging; Renal Artery; Renal Artery Obstruction; Risk Factors; Stroke

Background Early rapid declines of kidney function may occur in patients with atherosclerotic renal artery stenosis with institution of medical therapy. The causes and consequences are not well understood. Methods and Results Patients enrolled in the medical therapy-only arm of the CORAL (Cardiovascular Outcomes With Renal Artery Lesions) study were assessed for a rapid decline (RD) in estimated glomerular filtration rate (eGFR), defined as a ≥30% decrease from baseline to either 3 months, 6 months, or both. In the medical therapy-only cohort, eGFR was available in 359 subjects at all time points, the subjects were followed for a median of 4.72 years, and 66 of 359 (18%) subjects experienced an early RD. Baseline log cystatin C (odds ratio, 1.78 [1.11-2.85]; P=0.02), age (odds ratio, 1.04 [1.00-1.07]; P<0.05), and Chronic Kidney Disease Epidemiology Collaboration creatinine eGFR (odds ratio, 1.86 [1.15-3.0]; P=0.01) were associated with an early RD. Despite continued medical therapy only, the RD group had an improvement in eGFR at 1 year (6.9%; P=0.04). The RD and nondecline groups were not significantly different for clinical events and all-cause mortality (P=0.78 and P=0.76, respectively). Similarly, renal replacement therapy occurred in 1 of 66 (1.5%) of the RD patients and in 6 of 294 (2%) of the nondecline patients. The regression to the mean of improvement in eGFR at 1 year in the RD group was estimated at 5.8±7.1%. Conclusions Early rapid declines in kidney function may occur in patients with renal artery stenosis when medical therapy is initiated, and their clinical outcomes are comparable to those without such a decline, when medical therapy only is continued.

Topics: Aged; Cardiovascular Agents; Cause of Death; Disease Progression; Endovascular Procedures; Female; Glomerular Filtration Rate; Humans; Kidney; Male; Middle Aged; Prospective Studies; Renal Artery Obstruction; Risk Factors; Stents; Time Factors; Treatment Outcome; United States

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

Topics: Aged; Angioplasty, Balloon; Antihypertensive Agents; Blood Pressure; Cardiovascular Agents; Europe; Female; Follow-Up Studies; Humans; Hypertension; Kidney Function Tests; Male; Metals; Middle Aged; Prospective Studies; Prosthesis Design; Radiography; Recurrence; Renal Artery; Renal Artery Obstruction; Renal Insufficiency; Research Design; Sirolimus; Stents; Time Factors; Treatment Outcome; Vascular Patency

Atherosclerotic renal artery stenosis (ARAS) can reduce renal blood flow, tissue oxygenation, and GFR. In this study, we sought to examine associations between renal hemodynamics and tissue oxygenation with single-kidney function, pressor hormones, and inflammatory biomarkers in patients with unilateral ARAS undergoing medical therapy alone or stent revascularization.. Nonrandomized inpatient studies were performed in patients with unilateral ARAS (>60% occlusion) before and 3 months after revascularization (n=10) or medical therapy (n=20) or patients with essential hypertension (n=32) under identical conditions. The primary study outcome was change in single-kidney GFR. Individual kidney hemodynamics and volume were measured using multidetector computed tomography. Tissue oxygenation (using R(2)* as a measure of deoxyhemoglobin) was determined by blood oxygen level-dependent magnetic resonance imaging at 3 T. Renal vein neutrophil gelatinase-associated lipocalin (NGAL), monocyte chemoattractant protein-1 (MCP-1), and plasma renin activity were measured.. Total GFR did not change over 3 months in either group, but the stenotic kidney (STK) GFR rose over time in the stent compared with the medical group (+2.2[-1.8 to 10.5] versus -5.3[-7.3 to -0.3] ml/min; P=0.03). Contralateral kidney (CLK) GFR declined in the stent group (43.6±19.7 to 36.6±19.5 ml/min; P=0.03). Fractional tissue hypoxia fell in the STK (fraction R(2)* >30/s: 22.1%±20% versus 14.9%±18.3%; P<0.01) after stenting. Renal vein biomarkers correlated with the degree of hypoxia in the STK: NGAL(r=0.3; P=0.01) and MCP-1(r=0.3; P=0.02; more so after stenting). Renal vein NGAL was inversely related to renal blood flow in the STK (r=-0.65; P<0.001). Biomarkers were highly correlated between STK and CLK, NGAL (r=0.94; P<0.001), and MCP-1 (r=0.96; P<0.001).. These results showed changes over time in single-kidney GFR that were not evident in parameters of total GFR. Furthermore, they delineate the relationship of measurable tissue hypoxia within the STK and markers of inflammation in human ARAS. Renal vein NGAL and MCP-1 indicated persistent interactions between the ischemic kidney and both CLK and systemic levels of inflammatory cytokines.

Topics: Aged; Atherosclerosis; Biomarkers; Cardiovascular Agents; Cell Hypoxia; Chemokine CCL2; Endovascular Procedures; Female; Glomerular Filtration Rate; Humans; Inflammation Mediators; Kidney; Lipocalin-2; Magnetic Resonance Imaging; Male; Middle Aged; Multidetector Computed Tomography; Oxygen; Recovery of Function; Renal Artery Obstruction; Renal Circulation; Renin; Stents; Time Factors; Treatment Outcome

Topics: Angioplasty; Atherosclerosis; Cardiovascular Agents; Humans; Patient Selection; Renal Artery Obstruction; Risk Factors; Stents; Treatment Outcome

Topics: Aged; Angiography; Arterial Occlusive Diseases; Cardiovascular Agents; Delayed Diagnosis; Diagnosis, Differential; Female; Heart Failure; Hemodiafiltration; Humans; Hypertension; Hypertension, Renovascular; Iliac Artery; Kidney Transplantation; Postoperative Complications; Renal Artery Obstruction; Reoperation; Stents; Ultrasonography, Doppler

Topics: Animals; Atherosclerosis; Cardiovascular Agents; Humans; Renal Artery Obstruction; Vascular Surgical Procedures

Renal artery stenosis is a common finding among patients with atherosclerotic disease and its percutaneous treatment with stent implantation is frequently performed by interventional cardiologists and vascular radiologists. However, renal artery in-stent restenosis is not a rare complication and its management is not straightforward. We describe and report angiographic follow-up of an innovative approach to renal artery in-stent restenosis based on combined intravascular ultrasound and drug-eluting balloon treatment.

Topics: Aged, 80 and over; Angioplasty, Balloon; Cardiovascular Agents; Coated Materials, Biocompatible; Equipment Design; Humans; Male; Radiography; Recurrence; Renal Artery; Renal Artery Obstruction; Treatment Outcome; Ultrasonography, Interventional; Vascular Access Devices

Takayasu arteritis is an inflammatory condition that involves the large cardiac vessels, predominantly the aorta and its main branches. It typically affects young women (age, ≤40 yr), most often Asians and Latin Americans. Herein, we describe a rare manifestation of Takayasu arteritis in a 19-year-old black Tunisian man who presented with acute inferior myocardial infarction and complete atrioventricular block after occlusion from a giant aneurysm in the right coronary artery. The coronary artery disease was associated with aneurysmal dilations in the carotid, vertebral, and right renal arteries. Medical therapy improved Thrombolysis in Myocardial Infarction flow in the area of the giant aneurysm from grade 1 to grade 3. Upon the diagnosis of Takayasu arteritis, intravenous methylprednisolone and oral prednisone therapy was started. After 10 days of hospitalization, the patient was discharged on a medical regimen. Renovascular hypertension due to renal artery stenosis was suspected, so he underwent successful percutaneous transluminal angioplasty of the inferior segmental artery of the right renal artery. During 12 months of close postprocedural monitoring, he experienced lower blood pressure, no chest pain, and no cardiovascular complications.This association of conditions has not been previously reported. Besides presenting this very rare combination of findings, we discuss the differential diagnosis of Takayasu arteritis in our patient.

Topics: Angioplasty, Balloon; Atrioventricular Block; Cardiovascular Agents; Coronary Aneurysm; Coronary Angiography; Diagnosis, Differential; Electrocardiography; Glucocorticoids; Humans; Male; Myocardial Infarction; Predictive Value of Tests; Renal Artery Obstruction; Stents; Takayasu Arteritis; Treatment Outcome; Young Adult

Topics: Atherosclerosis; Cardiovascular Agents; Disease Progression; Endovascular Procedures; Evidence-Based Medicine; Humans; Hypertension; Patient Selection; Randomized Controlled Trials as Topic; Renal Artery Obstruction; Renal Insufficiency; Risk Assessment; Risk Factors; Stents; Treatment Outcome; Vascular Surgical Procedures

The role of and indications for interventions for renal artery stenosis have long been a hot topic of debate. Despite numerous reports and studies over the years, there remain many unanswered questions. Among them are: Who should be intervened upon? What should be the objectives of intervention? What is the optimal mode of intervention? More recently, several randomized studies have attempted to answer some of these basic questions, but unfortunately have left many unanswered questions. In the following debate, the authors consider the existing literature and attempt to convince us that the majority, or the minority, of patients with renal artery stenoses should be intervened upon.

Topics: Atherosclerosis; Cardiovascular Agents; Disease Progression; Endovascular Procedures; Evidence-Based Medicine; Humans; Patient Selection; Randomized Controlled Trials as Topic; Renal Artery Obstruction; Risk Assessment; Risk Factors; Stents; Treatment Outcome

The objective of this study was to analyze the use of sirolimus-eluting stent (SES) placement for the treatment of renal artery in-stent restenosis (RA-ISR). The optimal treatment of RA-ISR has not been fully elucidated to date. We retrospectively analyzed consecutive patients from our institution who underwent treatment of RA-ISR with a SES from May 2004 to June 2006. Using duplex ultrasound, RA-ISR (> 60% diameter) was determined by peak systolic velocity (PSV) > 300 cm/s and renal aortic ratio (RAR) > 4.0. Renal function (creatinine) and blood pressure were measured at baseline and follow-up. SESs were implanted in 16 patients (22 renal arteries) during the study period. The study cohort was predominantly female (75%) with a mean age of 68 +/- 12 years. RA-ISR was treated with SESs with a mean diameter of 3.5 mm and mean length of 17.9 +/- 3.8 mm. The mean post-dilation balloon diameter was 4.8 +/- 0.6. The baseline renal artery PSV was 445 +/- 131 cm/s with a mean RAR of 5.0 +/- 1.6. Follow-up information was available in 21 renal arteries. During a median follow-up of 12 months (range: 9-15 months), 15 renal arteries (71.4%) developed recurrence of ISR by ultrasonographic criteria. Univariate analysis revealed that female sex was an independent predictor of recurrence of ISR after SES implantation (p < 0.05). In conclusion, placement of a SES for the treatment of ISR in renal arteries is associated with high initial technical success but significant restenosis on duplex ultrasonography at follow-up.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon; Cardiovascular Agents; Drug-Eluting Stents; Female; Hemodynamics; Humans; Hypertension, Renovascular; Kidney; Male; Middle Aged; Radiography; Recurrence; Renal Artery Obstruction; Retrospective Studies; Risk Assessment; Risk Factors; Sirolimus; Stents; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex

Around 16% of all patients who present with atheromatous renovascular disease (ARVD) in the United States undergo revascularization. Historically, patients with advanced chronic kidney disease (CKD) have been considered least likely to show improvement in renal functional terms, or survival. We aimed to investigate whether differences in outcomes after revascularization compared to medical management might be observed in ARVD patients if stratified by their CKD classes.. Two prospective cohorts, a UK center with a traditionally conservative approach, and a German center who undertook a proactive revascularization approach, were compared. An improvement in renal function was defined as > 20% renal improvement at one year's follow-up. To improve validity and comparability, revascularized patients in the UK center were also used within analyses,. 347 (UK conservative group), 89 (UK revascularized group), and 472 (German center) patients were included in the analysis. When subdivided by CKD stage, patient ages between the two centers were comparable. Improvements in renal function were observed in twice as many patients who underwent revascularization as compared to medical treatment, particularly in the latter CKD stages, 15.2 (German revascularization) vs. 0% in CKD 1-2, 12.2 (UK), and 32.8 (German) revascularization vs. 14.1% in CKD3, and 53.1 and 53.8 vs. 28.3 in patients with CKD 4-5. The improvements in eGFR were 10.2 (16) and 8.1 (12.5) ml/min/year in the German and UK revascularized groups, respectively, vs. -0.05 (6.8) ml/min/year in the medical cohort in CKD 4-5. Improvements in blood pressure control were noted at 1 year overall and within each CKD category. Multivariate analysis revealed that revascularization independently reduced the risk of death by 45% in all patients combined (RR 0.55, P = 0.013).. Although this study has significant methodological limitations, it does shows that percutaneous renal revascularization can improve renal function in advanced CKD (stages 4-5), and that this can provide a survival advantage in prospective analysis.

Topics: Adult; Aged; Aged, 80 and over; Angioplasty, Balloon; Atherosclerosis; Cardiovascular Agents; Chronic Disease; Databases as Topic; Female; Germany; Glomerular Filtration Rate; Humans; Kidney; Kidney Diseases; Logistic Models; Male; Middle Aged; Odds Ratio; Prospective Studies; Recovery of Function; Renal Artery Obstruction; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Time Factors; Treatment Outcome; United Kingdom

Topics: Angioplasty, Balloon; Atherosclerosis; Cardiovascular Agents; Chronic Disease; Glomerular Filtration Rate; Humans; Kidney; Kidney Diseases; Recovery of Function; Renal Artery Obstruction; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Time Factors; Treatment Outcome

Renal artery stenosis may cause or exacerbate hypertension and renal failure. Percutaneous transluminal renal artery stent placement, increasingly the first-line therapy for ostial atherosclerotic renal artery stenosis, can be complicated by in-stent restenosis weeks to months after the procedure. There is currently no consensus for the treatment of in-stent restenosis. Sirolimus-eluting stents have been shown to be effective to treat in-stent restenosis in the coronary circulation. We report a case of sustained 24-month patency after repair of recurrent renal artery in-stent restenosis with use of a sirolimus-eluting stent.

Topics: Aged; Angioplasty, Balloon; Cardiovascular Agents; Drug-Eluting Stents; Humans; Hypertension, Renovascular; Male; Metals; Prosthesis Design; Radiography; Renal Artery Obstruction; Secondary Prevention; Sirolimus; Stents; Time Factors; Treatment Outcome; Vascular Patency

Percutaneous transluminal angioplasty (PTA) with or without stent insertion is the treatment of choice in transplant renal artery stenosis. However, in-stent restenosis occurs in as many as 13% of patients after PTA and stent insertion. This article describes three patients with recurrent transplant renal artery in-stent stenosis who were treated with paclitaxel-eluting stents. In two patients, the transplant renal artery remained patent after insertion of the drug-eluting stent (DES), and one patient required balloon angioplasty 7 months after the DES was inserted.

Topics: Adult; Aged; Angioplasty, Balloon; Cardiovascular Agents; Drug-Eluting Stents; Female; Humans; Kidney Transplantation; Magnetic Resonance Angiography; Male; Metals; Middle Aged; Paclitaxel; Prosthesis Design; Radiography; Recurrence; Renal Artery Obstruction; Stents; Treatment Outcome; Vascular Patency

Higher rates of clinical and angiographic restenosis have been reported after coronary stenting in patients with significant chronic kidney disease (CKD). Whether drug-eluting stents (DES) can reduce long-term clinical events in CKD patients compared with bare metal stents (BMS) has not been established.. The study enrolled 104 consecutive significant CKD patients (estimated creatinine clearance <60 ml/min) treated with DES for 142 de novo coronary lesions, comprising 76 patients treated with sirolimus-eluting stents (SES) for 106 lesions and 28 patients treated with paclitaxel-eluting stents (PES) for 36 lesions. Data from these patients were compared to those from a control group comprising 50 patients treated with BMS during the preceding 1 year.. There were no differences in terms of baseline clinical characteristics except that the patients of the DES group were older, had a higher ratio of insulin treatment for diabetes mellitus, and had a more frequent history of previous percutaneous coronary intervention. The patients in the DES group had more unfavorable lesion characteristics with smaller reference vessel diameter (2.8 mm versus 3.3 mm; P<0.001) and longer lesion length (28.8 mm versus 20.5 mm; P<0.001) than those in the BMS group. Compared to BMS, DES implantation had a lower 1-year major adverse cardiac events rate (cardiac death, non-fatal myocardial infarction or target vessel revascularization) (12% versus 26%; P=0.042). There were no significant differences between the SES and PES groups in terms of clinical outcomes.. DES implantation for de novo coronary lesions in significant CKD patients reduces 1-year clinical events compared with BMS implantation.

Topics: Cardiovascular Agents; Coronary Angiography; Coronary Restenosis; Drug-Eluting Stents; Female; Humans; Kidney Failure, Chronic; Male; Middle Aged; Paclitaxel; Renal Artery Obstruction; Retrospective Studies; Risk Factors; Sirolimus; Stents; Time Factors; Treatment Outcome

Reoccurrence of restenosis following angioplasty of renal instent restenosis is a considerable drawback of stent-supported angioplasty of renal artery stenosis especially in small vessel diameters. We therefore prospectively studied the long-term outcome of different techniques of endovascular treatment of reoccurrence of instent renal artery restenosis after primarily successful reangioplasty focusing on the impact of covered and drug eluting stents, respectively.. The study included 31 consecutive patients (33 lesions) presenting with their at least second instent restenosis following renal artery stenting who were included in a prospective follow-up program (mean follow-up 36+/-25 months, range 1-85). Primary endpoint of the study was the reoccurrence rate of instent stenosis after primarily successful treatment of instent restenosis determined by duplex ultrasound.. Primary success rate was 100%, no major complication occurred. Seven lesions were treated with balloon angioplasty (21%, group 1), 7 lesions with stent-in-stent placement (21%, group 2), 6 lesions with placement of a covered stent (18%, group 3), 3 lesions with a cutting balloon (9%, group 4), and 10 lesions with placement of a drug eluting stent (31%, group 5). During follow-up, overall 12 lesions (36%) developed reoccurrence of instent restenosis: n=5 in group 1 (reoccurrence rate 71%), n=3 in group 2 (43%), n=1 in group3 (17%), 3 in group 4 (100%), and n=0 in group 5 (0%). Treatment with a cutting balloon was the only significant predictor of restenosis (hazard ratio 32.3 (95% CI, 3.3-315.0); P<0.001).. Treatment of at least second renal artery instent restenosis is feasible and safe. Balloon angioplasty and the implantation of a bare metal stent, a covered stent, or a drug eluting stent seemed to offer favorable long-term patency, whereas cutting balloon angioplasty resulted in a very high rate of restenoses and should therefore be discouraged for this indication.

Topics: Adult; Aged; Angioplasty, Balloon; Cardiovascular Agents; Feasibility Studies; Female; Follow-Up Studies; Humans; Kaplan-Meier Estimate; Male; Metals; Middle Aged; Proportional Hazards Models; Prospective Studies; Prosthesis Design; Recurrence; Registries; Renal Artery; Renal Artery Obstruction; Reoperation; Risk Assessment; Risk Factors; Stents; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex; Vascular Patency

Topics: Angioplasty, Balloon; Cardiovascular Agents; Humans; Metals; Prosthesis Design; Recurrence; Renal Artery; Renal Artery Obstruction; Reoperation; Research Design; Risk Assessment; Risk Factors; Stents; Time Factors; Treatment Outcome; Vascular Patency