Clinical long-term results of percutaneous transluminal angioplasty in patients with peripheral arterial occlusive disease

BACKGROUND: We investigated the long-term clinical results of percutaneous transluminal angioplasty (PTA) in patients with peripheral arterial occlusive disease (PAOD) and the influence of different parameters on the primary success rate, the rate of complications and the long-term outcome. PATIENTS AND METHODS: We reviewed clinical and hemodynamic follow-up data of 166 consecutive patients treated with PTA in 1987 in our department. RESULTS: PTA improved the clinical situation in 79.4% of patients with iliac lesions and in 88.3% of patients with femoro-popliteal lesions. The clinical stage and ankle brachial index (ABI) post-interventional could be improved significantly (each P < 0.001), the same results were observed at the end of follow-up (each P < 0.001). Major complications occurred in 11 patients (6.6%). The rate of primary clinical long-term success for suprainguinal lesions was 55% and 38% after 5 and 10 years (femoro-popliteal 44% and 33%), respectively, the corresponding data for secondary clinical long-term success were 63% and 56% (60% and 55%). Older age (P = 0.017) and lower ABI pre-interventional (P = 0.019) significantly deteriorated primary clinical long-term success for suprainguinal lesions, while no factor could be identified influencing the outcome of femoro-popliteal lesions significantly. CONCLUSION: Besides an acceptable success rate with a low rate of severe complications, our results demonstrate favourable long-term clinical results of PTA in patients with PAOD.     

Renal artery surgery in the era of endovascular intervention

BACKGROUND: In the last decade the therapeutic concept of renovascular disease has changed. The numbers of primary surgical revascularisations have fallen substantially due to the invention of percutaneous transluminal angioplasty (PTA). PATIENTS AND METHODS: Retrospective data analysis. From September 1992 to December 2001, 42 patients were operated on 49 renal arteries at our institution. During the same period, 166 PTA of renal arteries alone and 92 PTA with stent were performed. Twenty-five patients and 27 renal arteries were operated encompassing an aortic reconstruction due to atherosclerosis (aortic occlusion 14, aortic aneurysm 11). The median age at operation was 61 years (range 47 years to 76 years). Four patients were operated on because of renal artery aneurysms with a diameter of more than 2.5 cm. The median age of these patients was 68.5 years (range 60 years to 77 years). Seven patients presented with atherosclerotic changes of the renal artery without aorto-iliac involvement. Their median age was 62.8 years at operation (range 39 years to 77 years). Of these, one suffered from rupture of the renal artery during PTA and needed emergency surgery: Six patients and 11 renal arteries with FMD were surgically reconstructed. RESULTS: The primary patency rate of all reconstructed renal arteries of surviving patients after 5 years was 92%, the secondary patency rate after 5 years was 98%. Two patients died perioperatively (4.7%). One patient had presented with a symptomatic thoraco-abdominal aneurysm and died ultimately because of a stroke. The second patient had an infrarenal AAA and died after a myocardial infarction. Twenty (47.7%) of all surgically treated patients had had at least one PTA preoperatively. CONCLUSION: During the last decade, primary surgical renal artery reconstruction was performed in about half of the cases. The decrease of primary open surgery of the renal arteries was most striking in patients with aorto-iliac occlusive disease. From 1996 on no patient of this group underwent open surgery without having had prior PTA of the renal arteries.     

腔内技术与主股动脉转流治疗TASCCD型主髂动脉病变的远期通畅率结果

目的:分析对比腔内技术与主股动脉转流治疗泛大西洋协作组(TASC)C D级主髂动脉病变的长期通畅率结果,为此类患者的手术选择提供依据。方法:回顾性分析安贞医院血管外科,2005年至2008年间,行腔内技术与主股动脉转流治疗TASC C D型主髂动脉病变77例(腔内治疗组35例,主股转流组42例),分析围手术期及远期预后,平均随访时间(59.7±18.7)个月。结果:腔内组5年一期通畅率68.8%,二期通畅率78.1%,总体生存率93.8%,总体保肢率90.6%;主股转流组5年一期通畅率92.1%,二期通畅率94.7%,总体生存率94.7%,总体保肢率97.3%。结论:腔内技术和主-股动脉转流治疗TASC C D型主髂动脉病变均可取得良好的远期疗效,但主-股动脉转流的远期通畅率更好。在无明显手术禁忌的情况下,应优先选择血管转流手术。     

Infrarenal Aortic Stenosis: Percutaneous Stent Therapy

Percutaneous therapy of distal abdominal aortic occlusive disease is an extension of the strategy for treating iliac artery occlusive lesions. The use of stents for these lesions offers the advantage of increased primary success and the potential for improved long-term patency. We present an illustrative case of primary stent therapy for a distal aorta occlusive lesion and describe the assessment of these patients and the technique of infrarenal aortic stent placement. Percutaneous stent therapy of these lesions offers an attractive alternative to surgical therapy in these patients.     

Percutaneous transluminal angioplasty of infrapopliteal arteries in patients with intermittent claudication: acute and one-year results.

In advanced stages of infrapopliteal peripheral arterial occlusive disease with critical ischemia of the lower limb, the efficacy of percutaneous transluminal angioplasty (PTA) is well established. In contrast, PTA is currently not the therapy of choice in intermittent claudication (IC). In this prospective study, patients with IC were treated percutaneously. Technical aspects and long-term results are presented. In 78 patients (61 males, or 78.2%; age, 71 +/- 11 years) with IC (Rutherford grade 2 or 3), 104 interventions were performed. At baseline, the initial/absolute walking distance (IWD/AWD) was 49 +/- 34/102 +/- 88 m; the ankle-brachial index (ABI) was 0.61 +/- 0.2 before and 0.49 +/- 0.2 after exercise. A crossover approach was used in 74% and an antegrade access in 26% of the cases. In 19 interventions (18.3%), the excimer laser technique was used, and in 26 interventions (25%) a total of 39 stents were implanted. Procedural success rate was 89.4%. IWD and AWD improved to 107 +/- 67 m and 167 +/- 74 m (P < 0.0001 vs. baseline each), respectively, and the ABI at rest and after exercise increased to 0.88 +/- 0.13 and 0.72 +/- 0.19 (P < 0.0001 vs. baseline each). Six complications occurred (5.8%). One embolic occlusion, two minor groin hematoma, one arteriovenous fistula, one compartment syndrome, and one perforation. All were treated conservatively. After 12 months, the primary patency rate was 66.3%, cumulative primary assisted patency rate was 81.9%, and secondary patency rate was 91.5%. Percutaneous revascularization of infrapopliteal arteries in patients with IC is feasible and associated with good acute clinical results and an encouraging long-term patency rate. The complication rate is low.     

Aorto-Femoral Bypass: A Multicenter Retrospective Study of 281 Cases

Aorto-femoral (A-F) bypass surgery has been performed commonly and safely as an interventional therapy for iliac arterial stenosis or obstruction. Recently, catheter intervention has increasingly replaced this modality. However, no consensus has been reached as to a lesion-specific treatment choice between bypass surgery and catheter intervention. We investigated the patency rates after A-F bypasses according to TransAtlantic Inter-Society Consensus (TASC) classifications. This is a multicenter retrospective analysis of 281 patients on whom A-F bypasses were performed between 1991 and 2000. Follow-up extended to a maximum of 10.0 years, with a mean of 3.6 years (±2.6 years). The overall primary patency rate for all grafts was 94.9% at 5 years. The patency rate for the TASC type-B lesion was lower than that of type-D lesion, with a survival rate at 5 years of 88.0%. The logistic regression analysis revealed that no variables were responsible for the primary patency rate. Renal failure, and peripheral arterial occlusive disease were correlated with a decreased survival rate. We conclude that the late results of A-F bypasses are satisfactory. For the type B lesion, catheter intervention may have a better indication. Chronic renal failure and peripheral arterial occlusive disease may decrease the survival rate. The operative indications should be carefully determined for these cases.     

Mid-term results of endovascular reconstruction for aorto-iliac obstructive disease.

AIM: Aorto-iliac obstructive disease has been traditionally treated with endarterectomy and/or a surgical bypass graft. Kissing-stents technique has been proposed to reconstruct the aorto-iliac bifurcation for complex aorto-iliac lesions. METHODS: We report 43 patients with complex aorto-iliac occlusions managed with endovascular repair. Between March 1999 and October 2005, a total of 43 patients with a mean age of 66+/-10 years underwent endovascular treatment for aorto-iliac obstructive disease. Lesions were classified C (n=34) and D (n=9), accordingly to the Trans-Atlantic Inter-Society Consensus (TASC) classification. All endovascular interventions were performed in the theatre under regional anesthesia. Predilation with kissing-balloons angioplasty was usually performed; the bifurcation was then eventually reconstructed using bilateral stents placed with the kissing technique. Clinical examination and duplex scans or computed tomography-angiography (CT-A) were performed at discharge and 1, 6, and 12 months after the procedure, with yearly studies thereafter. RESULTS: Kissing-stents technique was selectively used in 30 cases (69.7%); the remainder cases were treated with kissing-balloons. Major complications occurred in 2 patients (4.6%). Overall, mean hospitalization was 4.1+/-2.8 days (median 3 days). Mean follow-up was 32.4 months (range 1-84 months; median 36 months). During the follow-up, 2 patients (4.6%) died. Duplex and/or CT-A examination detected 4 re-occlusions. Primary patency rates at 12, 24, and 60 months were 92%, 85.7%, and 80.7%, respectively; overall secondary patency rate was 40/43 patients. CONCLUSIONS: We consider this approach most appropriate for patients deemed at high operative risk for conventional repair or for those who refuse surgery.     

Endovascular Therapy of Para-anastomotic Aneurysm Following Conventional Aortic Surgery

Objective: to describe the procedure and outcome of stent graft repair of para-anastomotic aneurysms (PAA) in the aorta and iliac vessels occurring after conventional open surgery for aortic aneurysm and occlusive disease.Design : analysis of prospectively collected data. Methods and results: five patients (age: 60–75 years) developed six para-anastomotic aneurysms after open surgery for abdominal aortic aneurysm or aorto-iliac occlusive disease. The PAAs were asymptomatic (average diameter 43 mm) and occurred either in the aorta (3) or iliac (3) vessels after an interval of 4–14 years. The PAAs were treated successfully in all cases, with no morbidity or mortality being observed.Conclusions : the technical success of the procedure is promising. If intermediate and long-lasting follow-up demonstrate durable results, stent graft repair will become the therapy of choice in the treatment of PAAs.     

Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels

OBJECTIVES: To compare stenting of aortic arch vessel obstruction with surgical therapy and to establish recommendations for treatment. BACKGROUND: Though surgery has been considered to be the procedure of choice for subclavian and brachiocephalic obstruction, little work has been done to compare it with stenting. METHODS: Eighteen patients with symptomatic aortic arch vessel stenosis or occlusion were treated with stenting, followed by periodic clinical follow-up and noninvasive arterial Doppler studies. Data were compared with the results as shown in a systematic review of a published series of surgery and stenting procedures which included comparison of technical success, complications, mortality and patency. RESULTS: Primary success in our series was 100% with improvement in mean stenosis from 84+/-11% to 1+/-5% and mean arm systolic blood pressure difference from 44+/-16 mm Hg to 3+/-3 mm Hg. There were no major complications (death, stroke, TIA, stent thrombosis or myocardial infarction). At follow-up (mean 17 months), all patients were asymptomatic with 100% primary patency. Literature review demonstrates equivalent patency and complications in the other published series of stenting. In contrast, there was a similar patency but overall incidence of stroke of 3+/-4% and death of 2+/-2% in the published surgical series. CONCLUSIONS: Subclavian or brachiocephalic artery obstruction can be effectively treated by primary stenting or surgery. Comparison of stenting and the surgical experience demonstrates equal effectiveness but fewer complications and suggests that stenting should be considered as first line therapy for subclavian or brachiocephalic obstruction.     

Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents

BACKGROUND: The long-term efficacy of sequential insertion of multiple plastic stents for benign biliary strictures is poorly defined. The aims of this study were to evaluate the long-term outcome (bile duct patency, complications) of this therapy and to identify predictors of a good outcome. METHODS: Retrospective review of 29 cases of benign biliary strictures treated with sequential plastic stent insertion in progressively increasing numbers and/or of increasing diameter. RESULTS: Stricture etiology was as follows: postoperative 19 (66%), chronic pancreatitis 9 (31%), and idiopathic 1 (3%). Therapy succeeded in 18 patients (62%) (mean follow-up 48.0 [11.56] months after stent removal). Therapy failed in 11 patients (38%) (mean interval to failure 11.59 [9.79] months after stent removal). The 2 groups of patients in which therapy failed had either a hilar stricture (n = 4, 25% success) or distal common bile duct stricture caused by chronic pancreatitis (n = 9, 44% success). In the remaining cases, therapy succeeded in 13 of 16 (81% success). The observed differences in success rate among subgroups were not statistically significant. There were no ERCP-related deaths. One episode of mild pancreatitis and 2 episodes of cholangitis developed during 126 ERCPs over a period of stent insertion of 36 patient years. CONCLUSIONS: In selected patients with benign biliary strictures, sequential endoscopic insertion of multiple biliary stents may lead to long-term success that could be equal to or superior to surgery with minimal morbidity. Hilar strictures and those caused by chronic pancreatitis appear to respond poorly to this therapy.     

Local longtime lysis in combination with percutaneous transluminal angioplasty (TPA)

In order to produce an endogenous lysis in case of local longtime lysis Urokinase is infused directly into the occlusion in a maximum dosage of 40,000 U/h via an arterial catheter. Remaining stenoses are extended by means of a dilatation catheter. The so far obtained results concerning 72 patients with very long and/or very old arterial occlusions show a primary success-rate of 96% and a 2 years' patency rate of 85% for all patients with a primary success of treatment. Complications and side-effects are scarce with this method. Therefore it can be applied with patients for whom other recanalising catheter methods are not indicated and with whom vascular surgery is not possible. However, a lasting success of treatment is only to be expected on the basis of the precise planning and careful performance of a long-term after treatment.     

Efficacy of subintimal angioplasty/stent implantation for long, multisegmental lower limb occlusive lesions in patients unsuitable for surgery.

PURPOSE: To investigate the feasibility and clinical outcomes of subintimal angioplasty combined with stent implantation in patients with long, multisegmental occlusive lesions unsuitable for surgical treatment. METHODS: Between 2003 and 2005, 30 patients (23 men; mean age 68 years, range 49-82) with severe claudication (Rutherford category 3, n=12) or critical limb ischemia (CLI; Rutherford category 4 or 5, n=18) underwent subintimal angioplasty with primary stenting for long (mean 28+/-11 cm) total occlusion in the lower limb arteries. Bypass surgery was considered unsuitable owing to inappropriate anatomy or poor distal runoff in 14 (47%) patients, severe coronary artery disease 14 (47%), or poor general condition in 2 (6%). RESULTS: Technical success was achieved in 27 (90%) of 30 cases. The 3 technical failures were due to inability to advance the wire, to re-enter the distal lumen, and vessel rupture, respectively. Three (10%) complications occurred (1 perforation, 2 hematomas) but did not require surgery. After a mean follow-up of 13+/-7 months (range 3-28), 10 (37%) cases of restenosis were found in 27 patients. At 12 months, the primary patency rate was 52%, and the limb salvage rate was 83%. CONCLUSION: Combined use of subintimal angioplasty and stent implantation was performed safely, with a relatively high success rate and acceptable intermediate-term clinical outcomes in patients with multisegmental, long occlusions of the lower limb arteries. Therefore, this strategy can be considered an option for symptomatic relief and limb salvage in patients unsuitable for bypass surgery due to various reasons.     

Treatment of Takayasu Arteritis in the Chronic Stages: An Analysis of 14 Operated Patients

The aim of this study was to evaluate clinical features, angiographic findings, surgical treatment, and the long-term results of surgical procedures in chronic phase of Takayasu Arteritis. Between 1989 and December 2000, 14 young female patients (mean age, 31 years) with occlusive lesions caused by Takayasu Arteritis were observed and treated at our department. All patients met the American College of Rheumatology 1990 criteria of classification of Takayasu Arteritis. Systemic symptoms were reported in fewer than 15%. All patients were evaluated by a routine full aortography. Occlusive disease was dominant (92.8%) and the subclavian and carotid arteries were mostly involved. All our patients underwent surgery and 30 vascular procedures were done. Polytetrafluoroehylene was the most common synthetic graft. The ipsilateral carotid artery was the most common proximal anastomotic site and the ascending aorta was used twice. Follow-up ranged from 1 to 9 years (mean 6 years) and there was no death. All patients had serial duplex and 6 at least one postoperative angiogram. Twenty percent of the bypass procedures were followed by complications. There was no difference between the complication rate using synthetic grafts or autologous veins. The actuarial graft patency rate was 96.4% at one year and 72% at 4 years. At side of the medical treatment which remains, to date, a subject of discussion, the long-term prognosis of Takayasu Arteritis depends on an elective surgical treatment, which requires full and accurate assessment of the lesions, best done by digital full arteriography. Surgical results are excellent with minimal morbidity and mortality.     

Peripheral arterial occlusive disease of the lower extremities

Disturbance of the arterial perfusion of the lower limbs with occlusion in the aorto-iliac area presents a broad field of operative treatment in younger patients below 70 years of age. In older people caution is necessary depending on preexisting multiple morbidity. If necessary, extra-anatomic bypass operations have to be taken into consideration in order to save a jeopardized leg. Limb salvage should be accomplished whenever possible. In case of involvement of the femoro-popliteal region even in old age patients aggressive surgery for limb salvage is important because of high mortality due to primary amputation and last not least because of better life quality and for cardiovascular training. Conservative treatment of occlusions in the aorto-iliac area is not promising much success. Therefore in this area vascular surgery is the treatment of choice. In contrary arterial occlusion of the femoro-popliteocrural region--especially if both are combined--can be positively influenced by conservative angiological regimen. Hence conservative therapy should always be tried first, before difficult and long lasting vascular reconstructions are taken into consideration. One should not forget that surgery of occlusive vascular disease is only a symptomatic therapy, not a curative one. Life expectancy is not enhanced, but only ability of walking is saved. Generally spoken, the patient with occlusive vascular disease of the lower limbs nowadays can be offered a differentiated and individualized therapy including, also, non-surgical procedures. Well planned reconstructive vascular surgery has a good long time prognosis saving the physical integrity and efficiency of the older patient suffering from disabling vascular alterations.     

Nitinol Stent Versus Bypass in Long Femoropopliteal Lesions: 2-Year Results of a Randomized Controlled Trial

ObjectivesThis study sought to compare patency rates and clinical outcomes of nitinol stents and primary vein bypass in long femoropopliteal lesions.BackgroundAn endovascular-first strategy for long femoropopliteal lesions is widely recommended without sufficient data comparing it with bypass surgery. Nitinol stents are widely used as the standard endovascular therapy.MethodsA single-center randomized controlled trial was performed with the primary endpoints of technical success, primary and secondary patency. Secondary endpoints were limb salvage, survival, complications, and clinical improvement.ResultsA total of 110 limbs (55 per group) in 103 patients were treated. Baseline and lesion characteristics were similar, with a mean lesion length of 276 mm. Critical limb threatening ischemia was the indication for treatment in 49% of limbs in both groups. Technical success was achieved in 87% in the stent group. During a 2-year follow-up, patency rates, limb salvage, survival and complications showed no significant differences between both groups. At 24 months, primary and secondary patency rates for the stent group were 60% and 72% versus 56% and 73% in the bypass group, respectively. Clinical improvement was significantly better in the bypass group.ConclusionsThere were no significant differences regarding patency rates, limb salvage, survival, or complications after 2 years. Technical success and clinical improvement in the bypass group were significantly better, but the promising results of the stent group suggest that an endovascular-first strategy for femoropopliteal lesions up to 30 cm may be reasonable. Mid- as well as long-term results need to be awaited.     

Efficacy of infrainguinal bypass for limb salvage in young diabetic patients

The efficacy of infrainguinal bypass for limb salvage in young diabetic patients has not been well established. The purpose of this study is to determine the intermediate-term results (patency and limb salvage) of infrainguinal revascularization carried out for limb salvage (rest pain or ulceration) in young (<50 years old) diabetic atherosclerotic patients. Thirty-nine bypasses in 31 patients with a mean age of 44 years were retrospectively reviewed. There were no perioperative deaths. Minor or major complications occurred in 23% of cases. By life table analysis, the 18-month primary patency rate was 60+/-11%, assisted primary patency rate was 78+/-9%, and limb salvage rate was 71+/-9%. Most major amputations (five of nine) were required in patients with functional bypasses, either because of persistent infection or failure of wound healing. The presence of severe stenoses (>70%) in all three major named foot vessels (dorsalis pedis, medial and lateral plantar arteries) was associated with a high likelihood of limb loss despite a patent bypass (p<0.05). We could not identify any other factors statistically predictive of thrombosis, amputation, or the need for graft revision. Infrainguinal revascularization in this patient population can be carried out with acceptable limb salvage rates. However, patients should be made aware of the high incidence of amputation regardless of the success of the revascularization procedure, particularly in the presence of severe occlusive disease within the foot.     

Direct coronary angioplasty in acute myocardial infarction: outcome in patients with single vessel disease

Percutaneous transluminal coronary angioplasty was performed as primary therapy in 215 consecutive patients (aged 56 +/- 11 years, 75% male) with acute myocardial infarction and single vessel coronary artery disease. Wide patency of the infarct-related artery was restored in 212 patients (99%). Complications consisted of one urgent coronary bypass operation (0.5%); there were no procedural deaths. A recurrent ischemic event before discharge occurred in eight patients (4%). The in-hospital mortality rate was 1%; five of six patients presenting with cardiogenic shock were alive at discharge. In 126 patients in whom predischarge angiography was performed, the ejection fraction improved from 55 +/- 12% to 61 +/- 12% (p less than 0.005) and increased by greater than or equal to 5% units in 66 patients (52%). Regional wall motion improved in 60 patients (48%). By multivariate analysis, a depressed initial ejection fraction, a limited increase in serum creatine kinase, young age and sustained patency of the infarct-related artery were found to be independent predictors of improvement in left ventricular function. Follow-up data were available in 214 patients (99.5%) at a mean interval of 35 months. The actuarial 3 year cardiac survival rate was 92%. By multivariate analysis, only the baseline ejection fraction correlated with long-term cardiac survival. Nine patients (4%) sustained a late nonfatal myocardial infarction, and 11 patients (5%) underwent subsequent coronary bypass surgery. At late follow-up study, 149 (77%) of 194 patients alive were free of angina. In summary, in patients with acute myocardial infarction and single vessel disease, coronary angioplasty without prior thrombolytic therapy can be performed with a high success rate and few procedural complications. After direct angioplasty, regional wall motion and global ejection fraction improve in 50% of patients, especially in those with depressed initial left ventricular function. This approach results in an excellent early and late event-free survival.     

Long-term results and its managements after coronary bypass surgery

Between 1970 and 1985, 221 patients with coronary artery occlusive disease underwent aorto-coronary bypass (A-C bypass) and other procedures. Among these patients, 187 had A-C bypass alone and A-C bypass in addition to correction of valvular lesions or arterialization of the coronary vein, myocardial puncture by laser. The remaining 34 had surgical corrections for myocardial infarction and its complications. Subjects were 100 patients who underwent A-C bypass alone over 6 months ago and whose follow-up study could be performed in 93 survival cases [corrected]. Subsequently, 94% of the patients have met the criteria for grade I of NYHA functional capacity and have returned to normal work at a mean of 4 years and 2 months after surgery. Improved left ventricular function has been maintained postoperatively in the patients with complete revascularization. Improved operative technique, in addition to intraoperative balloon angioplasty and onlay patch grafting, have increased the patency rate (78% in 1 mm, 94% in 2 mm of coronary diameter) of the grafts with postoperative anticoagulant therapy. On the basis of our long-term observations, coronary bypass surgery, particularly in complete revascularization, provides for significant improvement in both the quality and life expectancy of patients with severe coronary heart disease. Treadmill exercise test and magnetic resonance image (MRI) were useful, non-invasive and acceptable examinations in long-term follow up.     

Renal Artery Stent Placement: Indications and Results

Although revascularization of renal artery stenosis (RAS) from fibromuscular dysplasia (FMD) generally yields satisfying outcomes, traditional approaches to revascularization for atherosclerotic renal artery stenosis (ARAS) have been suboptimal because of the invasiveness, relatively high perioperative morbidity and mortality rates of surgery, and the low rates of technical success and long-term patency with percutaneous renal balloon angioplasty (PTA). Endovascular stents have been deployed for failed PTA (unsatisfactory results or complications) and treatment of restenotic lesions. Compared to PTA, primary stenting of ostial ARAS gives superior technical success rates greater than 95% and improved long-term patency. Curing hypertension after RAS revascularization is rare (< 10%). Improved control with fewer medications is a more realistic goal. Renal function as judged by serum creatinine improves in 20% to 30%, stabilizes in 40% to 60%, and deteriorates in 20% to 30% of patients whose renal function is impaired initially. One study demonstrated successful stenting slowed the rate of progression of renal failure in 89% of patients whose serum creatinine was less than 400 mol/L. Complications of renal artery stenting may be substantial, though procedure-related mortality is low. Patient selection for renal revascularization remains controversial. Those with renovascular disease and uncontrolled hypertension, progressive renal failure, or recurrent flash pulmonary edema should be carefully considered for renal artery stenting in experienced centers.     

Intraluminal Palmaz stent implantation for treatment of recurrent carotid artery occlusive disease: a plan for the future

While carotid endarterectomy (CEA) has been used commonly and with great effectiveness for de novo carotid occlusive lesions, its success in cases of recurrent disease has been attenuated by a higher incidence of complications and lower durability. Although interventional techniques have been introduced cautiously into the cerebrovascular system, balloon dilation for both primary and recurrent carotid atherosclerotic disease has been successful in establishing an adequate lumen without an increase in embolic complications over surgery. Because the likelihood exists that postdilation restenosis may be as common in the carotid arteries as it is in other vascular segments, the use of intraluminal stenting may mitigate this long-term complication, a benefit that has been demonstrated in other high flow vessels such as the aorta and iliac arteries. To begin an investigation of this hypothesis, we treated a 69-year-old symptomatic man who required a third intervention for recurrent carotid disease. A > 90% stenosis of the distal third of his right common carotid artery was successfully dilated, and a Palmaz stent was deployed without incident. The patient experienced no complications to the percutaneous procedure, and at 15 months posttreatment, he is well and asymptomatic. Although greater clinical experience must be accumulated with this new approach, intraluminal stenting following balloon dilation for recurrent carotid disease may surpass redo CEA in long-term patency and may entail fewer procedural complications.